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A  TEXT-BOOK   OF 

MINOR   SURGERY 


A  TEXT- BOOK  OF 

MINOR   SURGERY 


BY 

EDWARD   MILTON   FOOTE,  A.M.,  M.D. 

CONICAL    PROFESSOR    OF    SDRGERY,    NEW   YORK    POLYCLINIC    MEDICAL    SCnOOL    AND    HOSPITAL;     VISITING 

SURGEON,    NEW    YORK    SKIN    AND    CANCER    HOSPITAL.    AND    ST.    JOSEPH'S   HOSPITAL; 

CONSULTING   SURGEON,   RANDALL'S   ISLAND   HOSPITALS   AND   SCHOOLS 

FORMERLY   CHIEF   IN   SURGERY   AT   THE   VANDERBILT   CLINIC,    AND   INSTRUCTOR   IN    SURGERY, 
COLLEGE   OF   PHYSICIANS   AND   SURGEONS    (COLUMBIA   UNIVERSITY) 


o 


FOURTH  EDITION 

ILLUSTRATED  BY  FOUR  HUNDRED  AND  THIRTY-THREE  ENGRAV- 
INGS FROM  ORIGINAL  DRAWINGS  AND  PHOTOGRAPHS 


D.   APPLETON    AND    COMPANY 

NEW  YORK    AND    LONDON 

1914 


■1. 


-f13 


Copyright,  1907,  1909,  1911,  1914,  bt 
D.  APPLETON   AND  COMPANY 


Printed  in  the  United  Slates  of  America 


THIS   BOOK   IS   DEDICATED   TO 

THE    MAN   AT   THE   POINT   OF   THE   KNIFE 

FOR   HIS   GRIT   AND    PATIENCE,    AND   ESPECIALLY   FOR 

HIS    WILLINGNESS    TO    BE    PHOTOGRAPHED 

THAT   OTHERS   MAY   PROFIT   BY 

HIS   MISFORTUNE 


PREFACE  TO  THE  THIRD  EDITION 


A  chapter  on  General  Anesthesia  has  been  added  to  meet  the 
suggestions  of  many  friends.  The  aim  in  writing  this  chapter 
has  been  distinctly  a  practical  one.  The  subject  of  anesthesia  has 
excited  such  widespread  interest  in  the  last  few  years  that  every 
physician  who  takes  an  inhaler  in  his  hand  ought  to  know  the 
good  and  bad  points  of  the  anesthetics  in  common  use.  An  attempt 
is  made  to  give  such  information  in  a  non-technical  form.  For  the 
good  of  the  country  it  is  hoped  that  many  young  physicians  will 
decide  to  make  anesthetics  a  specialty.  Those  who  do  so  will  natu- 
rally provide  themselves  with  books  devoted  exclusively  to  the  sub- 
ject of  anesthetics.  While  we  are  waiting  for  the  arrival  of  the 
professional  anesthetist  in  every  town,  anesthetics  must  still  be  given 
by  men  engaged  in  other  practice.  It  is  for  these  men  and  for  the 
beginner  in  anesthesia  that  this  chapter  is  written. 

If  it  seems  to  some  that  too  great  a  space  is  devoted  to  the 
methods  of  vapor  anesthesia,  the  answer  is  that  the  author  is  firmly 
convinced  that  this  is  the  anesthesia  of  the  future,  although,  per- 
haps, the  form  of  apparatus  may  be  different  from  any  at  present 
in  use.  The  skill  with  which  vapor  anesthesia  is  administered  to 
animals  in  physiological  laboratories,  and  with  practically  no  risk, 
ought  to  be  a  stimulus  at  least  to  hospital  surgeons  to  provide 
equally  good  facilities  for  their  patients. 

Edward  Milton  Foote. 

135  West  Forty-Eighth  Street, 
New  York  City. 


PREFACE 


In  preparing  this  "  Minor  Surgery/'  it  has  been  my  purpose  to 
apply  to  the  less  serious,  every-day  problems  of  surgical  practise  the 
new  knowledge  which  the  discoveries  of  the  last  twenty- five  years 
have  revealed.  During  this  period  the  advances  in  diagnosis  and 
treatment  have  rendered  necessary  a  new  surgical  literature,  and  many 
excellent  text-books  have  appeared,  in  one,  two,  and  four  volumes. 
In  these  the  more  serious  surgical  conditions  are  exhaustively  dis- 
cussed, while  the  treatment  of  the  lesser  ailments — the  minor  surgery 
which  forms  the  bulk  of  surgical  practise — is  condensed  into  a  chapter 
or  two,  in  which  methods  of  treatment  long  since  outgrown  still  find 
their  place.  JSTor  is  the  importance  of  minor  surgery  recognized  in 
the  curriculum  of  our  medical  schools. 

And  yet  this  neglected  field  of  minor  surgery  is  the  only  one  into 
which  the  average  practitioner  will  ever  enter,  and  is  also  the  one 
in  which  most  surgeons  will  find  the  majority  of  their  patients.  What 
wonder  then  that  the  physician,  untaught  and  unread  in  minor  sur- 
gery, fails  to  achieve  good  results,  and  that  more  bad  surgery  is  per- 
formed upon  the  hand  than  upon  the  organs  of  the  abdomen  ? 

Impressed  by  the  need  of  a  text-book  which  describes  in  detail 
the  manifold  lesser  accidents  and  surgical  diseases  which  the  general 
practitioner  is  called  upon  to  treat,  I  commenced  eight  years  ago 
the  preparation  of  such  a  book.  It  has  been  rewritten  several  times, 
until  hardly  a  page  of  the  original  manuscript  remains;  and  it  ap- 
pears now  in  its  development,  somewhat  larger,  but  the  same  in  pur- 
pose as  when  it  was  first  conceived. 

If  this  "  Minor  Surgery  "  fails  to  meet  the  expectations  of  the 
reader,  this  fault  does  hot  lie  in  the  author's  lack  of  experience ;  for  I 
had  the  richest  opportunity  for  the  preparation  of  just  such  a  book  in 
a  ten  years'  almost  daily  service  in  the  Surgical  Department  of  the 


X  PREFACE 

Yanderbilt  Clinic,  with  an  average  annua]  attendance  of  about  four 
thousand  new  patients.  Besides  this  I  have  enjoyed  the  advantages 
which  come  from  teaching  both  minor  surgery  and  general  surgery 
in  the  College  of  Physicians  and  Surgeons,  and  from  surgical  at- 
tendance in  the  Randall's  Island  Hospitals,  the  New  York  City  Hos- 
pital, and  the  New  York  Polyclinic  Hospital. 

I  have  striven  to  present  in  compact  form  the  results  of  this  ex- 
perienee  and  the  best  that  has  been  written  in  hooks,  magazines,  and 
journals,  taking  with  free  hand  from  every  available  source.  A  mere 
list  of  the  articles  consulted  would  lill  several  pages.  Very  few  au- 
thors' names  are  mentioned  because  such  simple  procedures  as  are 
herein  described  must  often  suggest  themselves  to  many  minds.  We 
all  owe  so  much  to  our  predecessors. 

The  aim  has  been  to  illustrate  by  .photographs  as  far  as  possible. 
Too  often  medical  illustrations  show  what  might  be,  rather  than 
what  is;  for  the  difficulties  of  making  clinical  photographs  sufficiently 
clear  for  good  reproduction  are  tremendous.  Mr.  H.  C.  Lehmann 
has  aided  me  very  much  in  this  part  of  the  work,  and  has  also  fur- 
nished all  of  the  drawings.  My  thanks  are  also  due  to  Dr.  E.  J. 
McKenzie  for  many  good  photographs  made  while  he  was  a  student 
in  my  clinic;  and  to  Mr.  B.  F.  Puffer,  who  took  for  me  the  photo- 
graphs to  illustrate  the  chapter  on  bandaging. 

Edward  Milton  Foote. 

135  West  Forty-eighth  Street, 
New  York. 


CONTENTS 


SECTION  I 
AFFECTIONS  OF  THE  HEAD 

PAGE 

Chapter  I. — Injuries  op  the  Head 

General  considerations  . 1 

Contusions:  Subconjunctival  ecchymosis — Hematoma  of  the  new- 
born; of  the  ear. 

Hemorrhage:  From  the  nose 2 

Abrasions:  Removal  of  powder  grains 7 

Foreign  bodies 8 

Foreign  body  in  the  eye;  ear  and  nose;  mouth  and  throat. 

Wounds    .  13 

Wounds  of  the  eye;  mouth;  Steno's  duct;  periosteum. 

Fractures 17 

Fracture  of  skull;  into  frontal  sinus;  of  malar;  of  nasal;  of  superior 
maxilla;  of  inferior  maxilla;  complications. 

Dislocation  of  the  jaw:  Subluxation 24 

Chapter  II. — Inflammations  of  the  Head 

Effects  of  heat  and  cold 25 

Burns — Sunburn;   of  lip — X-ray  burn — Frost-bite — Dermatitis. 
Acute  inflammations 31 

Urticaria  —  Herpes  —  Impetigo  —  Acne  —  Cellulitis  —  Erysipelas 

— Boil — Stye  —  Boils   of   the   nose   and   ear — Abscess — Alveolar 

Abscess. 
Inflammations  of  the  eye 47 

Acute    conjunctivitis — Purulent    conjunctivitis — Granular   lids — 

Trachoma — Ingrowing  lashes. 

Inflammation  of  the  ear:  Otitis  media 51 

Inflammations  of  the  nose 53 

Acute   rhinitis — Chronic   rhinitis — Suppuration   in  frontal  sinus; 

in  antrum  of  Highmore. 
Inflammations  of  the  mouth  and  throat 55 

Stomatitis    and    gingivitis — Peritonsillar    abscess — Retropharyn- 
geal abscess. 
Inflammations  of  the  skin     .        .        .        . ' 57 

Eczema — Ringworm — Ulcer — Anthrax — Noma. 
Chronic  inflammations   .        .        .      •  .        .        .        .        .        .        .        .59 

Syphilis:    Secondary    lesions;    tertiary    lesions — Tuberculosis    of 

nose  and  mouth — Actinomycosis. 

ad 


Xll  CONTENTS 

p  \<;  i; 

Chapter  III.— Ti  mors  and  Deformities  op  the  Head 

Cystic  tumors Gl> 

Milium     Comedo— Seliaceous  cyst      Mucous  cysl      Salivary  cysts 

— Dental  cysi     Dermoid  cyst— Congenital  sinus. 
Benign  solid  tumors 76 

Papilloma  —  Mole — Lipoma—  -  Fibrolipoma    -Angioma     Nevus — 

Acne   hypertrophies     Hypertrophy   of   tonsil-  Adenoids — Epulis 

— Otoliths — Osl  coma     Spur. 
Malignant  tumors 92 

Epithelioma  of  scalp;  of  lace;  of  li|>;  of  tongue— Sarcoma  —Angio- 
sarcoma   -Parotid  tumors — Cancer  of  tonsil. 
Acquired  deformities 108 

Cicatrices — Nasal  deformities — Deviation   of   septum   -Elongation 

of  uvula. 
Congenital  deformities 112 

Harelip — Cleft  palate — Cleft  lower  lip — Thick  lips — Tongue  tie — ■ 

Deformities  of  ear. 


SECTION   II 
AFFECTIONS  OF   THE  NECK 

Chapter  IV. — Injuries  and  Inflammations  op  the  Neck 

Contusions 117 

Foreign  bodies 117 

Foreign  bodies:  of  larynx;  of  trachea;  of  esophagus. 

Wounds 118 

Wounds  of  vessels;  of  trachea;  of  esophagus — Tracheotomy — 
Intubation 

Sprain  of  cervical  spine 122 

Fractures •        •        .123 

Fracture  of  hyoid;  of  larynx;  of  trachea;  of  vertebra. 

Dislocation  of  vertebra 12-5 

Inflammations 125 

Burn  —  Cellulitis  —  Erysipelas  —  Boil — Carbuncle — Abscess — An- 
gina ludovici — Anthrax — Tuberculosis  of  vertebra. 

Chapter  V. — Tumors  and  Deformities  of  the  Neck 

Tumors 135 

Sebaceous  cysts — Thyroid  cyst — Thyreoglossal  cyst — Branchio- 
genic  cyst — Lipoma:  Simple,  diffuse,  intermuscular — Fibroma 
— Lymphadenitis:  Acute;  tuberculous;  syphilitic;  in  leukemia;  in 
pseudoleukemia;  in  sarcoma;  in  carcinoma — Goiter. 

Acquired  deformities 147 

Cicatrices — Wryneck. 


CONTENTS  XI 11 

SECTION   III 
AFFECTIONS  OF   THE  TRUNK 

PAGE 

Chapter  VI. — Injuries  and  Inflammations  of  the  Trunk 

Contusions        . 153 

Contusion  of  breast;  of  back  and  ribs;  of  abdomen. 

Wounds 156 

Hemorrhage  from  umbilicus — Gunshot  wound  of  back — Pene- 
trating wound  of  pleural  cavity;  of  pericardial  cavity;  of  abdomen. 

Sprains 158 

Sprain  of  back — Railroad  spine. 

Fractures 163 

Fracture  of  clavicle;  of  scapula;  of  sternum;  of  ribs;  of  vertebra. 

Dislocations ' 169 

Dislocation  of  clavicle;  of  costal  cartilage;  of  vertebra. 

Acute  inflammations 170 

Burns — Insect  bites — Scabies — Herpes  zoster — Cellulitis — -Derma- 
titis— Erysipelas — Abscess  of  breast;  of  umbilicus — Bed-sore — 
Empyema. 

Chronic  inflammations 177 

Syphilis — Tuberculosis  of  sternoclavicular  joint;  of  ribs;  of  verte- 
brae; of  sacroiliac  joint;  of  mammary  gland. 

Chapter  VII. — Tumors  and  Deformities  of  the  Trunk 

Cystic  tumors 181 

Sebaceous  cyst — Umbilical  cyst — Coccygeal  cyst — Dermoid  cyst — 

Cysts  of  mammary  gland. 
Solid  benign  tumors  of  trunk 183 

Granuloma — Keloid — Papilloma — Fibrolipoma — Lipoma. 
Solid  tumors  of  breast 187 

Hypertrophy — Adenoma — Early  diagnosis  of  malignant  tumors — 

Tumors  of  male  breast. 
Malignant  tumors  of  trunk:  Carcinoma  and  sarcoma  of  skin         .        .191 
Acquired  deformities 192 

Coccygodynia — Hernia:  Umbilical;  inguinal;  femoral;  strangulated 

— Ascites — Paracentesis. 
Congenital  deformity:  Spina  bifida .      201 


SECTION  IV 

AFFECTIONS  OF   THE  GENITO-URINARY  ORGANS 

Chapter  VIII. — -Injuries  and  Inflammations  of  the  Male  Genito- 
urinary Organs 

Subcutaneous  injuries 203 

Contusion    of    penis    and    testicle — Hematoma — Hematocele — 
Fracture  of  penis — Paraphimosis — Neuralgia  of  testicle. 


XIV  CONTENTS 

PAGE 

Foreign  bodies 200 

Foreign  bodies  of  penis;  of  urethra;  of  bladder. 

Wounds:  Rupture  of  urethra;  of  bladder 208 

Acute  inflammations 210 

Burns  -  Balanitis  — Herpes  —  Urethritis — Abscess — Gonorrhea — 
Cystitis— Epididymitis — Posterior  urethritis — Stricture  —  Reten- 
tion of  urine  —  Incontinence —  Catheterization — Eczema — Chan- 
croid— Inguinal  adenit  is. 

Chronic  inflammations 225 

Syphilis — Mixed  infection — Syphilitic  orchitis — Tuberculosis  of 
testicle. 

Chapter  IX. — Tumors  and  Deformities  of  the  Male  Genito-Urinary 
Organs 

Tumors 231 

Cysts  of  skin;  of  testicle — -Warts — Epithelioma — Carcinoma — 
Sarcoma — Castration — Tumors  of  I 'ladder  and  prostate. 

Acquired  deformities 236 

Hydrocele — Hydrocele  of  the  cord— Varicocele. 

Congenital  deformities 244 

Phimosis — Circumcision — Short  frenum — Narrow  meat  us — Hypo- 
spadias— Epispadias — Exstrophy  of  bladder — Undescended  testi- 
cle. 

Chapter  X. — Affections  of  the  Female  Genito-Urinary  Groans 

Injuries 25/5 

Contusions — Rupture  of  hymen;  of  vagina — Hematoma — -Acute 
laceration  of  perineum — Hemorrhage — Rape. 

Foreign  bodies 258 

Foreign  bodies  of  vagina;  of  urethra;  of  bladder. 

Acute  inflammations 2(i0 

Pruritus — Eczema — Simple  vulvitis  and  vaginitis — Acute  gonor- 
rhea; of  vulva;  of  urethra;  of  Bartholin's  glands — Simple  suppu- 
ration. 

Chronic  inflammations 264 

Chronic  gonorrhea — Endocervicitis — Endometritis — Dilatation — 
Currettage — Chancroid — Syphilis — Chancre— Condyloma. 

Tumors 270 

Cyst  of  Bartholin's  gland — Urethral  caruncle — Cervical  polyp — ■ 
Carcinoma;  of  vulva;  of  cervix. 

Acquired  deformities 272 

Relaxation  of  sphincter  of  bladder — Incontinence  of  childhood — 
Retention  of  urine — Catheterization — Prolapse  of  urethra — Old 
laceration  of  perineum — Prolapse  of  uterus — Fistula  of  vagina;  of 
urethra. 

Congenital  deformities 277 

Adhesions  of  clitoris — Imperforate  hymen — Stenosis  of  cervix. 


CONTENTS  XV 

SECTION   V 
AFFECTIONS  OF   THE  ANUS  AND  RECTUM 

PAGE 

Chapter  XL — Injuries  and  Inflammations  of  the  Anus  and  Rectum 

Injuries 280 

Examination  of  patient — Stretching  of  sphincter  ani — Wounds — 

Hemorrhage. 

Foreign  bodies:  Impacted  feces 286 

Acute  inflammations - 286 

Intertrigo  —  Pruritus  —  Proctitis  —  Fissure  —  Abscess — Fistula — 

Gonorrhea — Chancroid. 
Chronic  inflammations 300 

Syphilis — Tuberculosis — Ulcer  of  Rectum — Stricture. 
Chapter  XII. — Tumors  and  Deformities  of  the  Anus  and  Rectum 

Tumors 307 

Venereal  warts — Polyp — Hemorrhoids:  Acute;  chronic — Carcinoma 

— Sarcoma. 
Acquired  deformities 318 

Prolapse:  Acute;  chronic — Rectal  hernia — Incontinence  of  sphinc- 
ter ani. 

Congenital  deformities 322 

Imperforate  anus — Stricture. 


SECTION  VI 

AFFECTIONS  OF   THE  ARM  AND  HAND 

Chapter  XIII. — Injuries  to  the  Soft  Parts  of  the  Arm  and  Hand 

Subcutaneous  injuries .•      324 

Contusion — Blister — Hematoma — Rupture  of  muscle. 

Wounds 32S 

Minute  wounds — Ligation  of  vessels — Suture  of  tendons;  of 
nerves — Wounds  of  joints. 

Foreign  bodies         . 336 

Sprains 338 

Sprain  of  shoulder — Neuritis — Acute  tenosynovitis:  Serous  syno- 
vitis—Bursitis. 

Chapter  XIV. — Dislocations  and  Fractures  of  the  Arm  and  Hand 

Dislocations .'....      347 

Dislocation  of  shoulder;  of  elbow;  of  radius;  of  ulna — Subluxation 
of  radius — Dislocation  of  wrist;  of  thumb — Overextension  of 
thumb — Dislocation  of  finger — Drop-finger. 

Fractures 363 

Separation  of  epiphysis — Green-stick  fracture — Fracture  of 
humerus;  of  olecranon;  of  head  of  radius;  of  shaft  of  ulna  or 
radius — Fracture:  Colles's;  of  carpus;  of  metacarpals;  of  phalanges 
— Compound  fractures — Crushed  fingers — Amputation  of  fingers. 


XVI  CONTENTS 

PAGE 

Chapter   XV.     Inflammations  of  the  Arm  and  Hand 

Effects  of  heal  and  cold 393 

Burns  Mangle  injury  Frost-bite  Chilblains — Gangrene:  Car- 
bolic, etc.;  with  cellulitis;  diabetic. 

Acute  inflammations 399 

Infect  ion  in  wounds — Anatomical  tubercle — Dermal  it  is — Erysipe- 
las—  Erysipeloid-  -Cellulitis  Boil  -Paronychia:  Acute;  chronic — 
Thecitis — Suppurating  synovitis — Arthritis — Bursitis — Lymphan- 
gitis— Lymphadenitis — Eczema — -Ulcer  from  vaccination. 

Arthritic  and  chronic  inflammations 433 

Rheumatism — Gonorrheal  arthritis — Deforming  art  hril  is-  •<  lout 
— Syphilis — Tuberculosis  of  tendon  sheaths;  of  joints  Osteo- 
myelit  is. 

Chapter  XVI. — Tumors  and  Deformities  of  the  Arm  and  Hand 

Tumors 445 

Ganglion — Aneurism — Varix — Inclusi*  >n  cyst — Lipoma — Fibroma 

— Papilloma  —  Neurofibroma  —  Osteoma  —  Granuloma  —  Wart 

— Epithelioma — Sarcoma. 
Acquired  deformities 463 

Cicatricial  contractions — Dupuytren's  contraction. 
Congenital  deformities 467 

Weli-Cmger — -Supernumerary     finger — Hypertrophy     of     finger — 

Deficiency  of  finger— Too  many  accessory  tendons. 


SECTION  VII 
AFFECTIONS  OF   THE  LEG  AND   FOOT 

Chapter  XVII. — Injuries  of  the  Leg  and  Foot 

Injuries 471 

Contusions — Abrasions — Blister — Hematoma:  Subungual;  sub- 
periosteal— Rupture  of  vein;  of  tendon. 

Wounds ■ 475 

Wounds  of  joint;  of  tendon;  of  nerve. 

Bursitis 476 

Bursitis:  Prepatellar;  subgluteal;  back  of  knee;  under  tendo 
Achillis;  metatarsophalangeal — Serous  synovitis — Float  ing  cartil- 
age. 

Sprain 486 

Sprain  of  hip;  of  knee;  of  ankle — Chronic  synovitis — Rupture  of 
ligament. 

Dislocation 497 

Fractures 497 

Fracture  of  femur;  of  patella;  of  tibia  (non-union);  of  fibula;  of 
lower  end  of  tibia  and  fibula;  of  astragalus;  of  os  calcis;  of  meta- 
tarsals; of  phalanges. 

Amputation 509 


CONTENTS  XVll 

PAGE 

Chapter  XVIII. — Inflammations  op  the  Leg  and  Foot 

Effects  of  heat  and  cold 511 

Frost-bite — Burns — Gangrene. 

Acute  inflammation 514 

Cellulitis — Lymphangitis — -Phlebitis — Thrombosis — Lymphadeni- 
tis— -Abscess — Pediculosis. 

Chronic  and  arthritic  inflammations 519 

Eczema — Ulcer — Perforating  ulcer  —  Suppurating  synovitis — ■ 
Rheumatism — Gonorrheal  arthritis — Gout — Syphilis — Tuberculo- 
sis. 

Chapter  XIX. — Tumors  and  Deformities  of  the  Leg  and  Foot 

Tumors 537 

Callus — Corn — Varicose  veins — Aneurism — -Ganglion — Sebaceous 
cyst — Lipoma — Fibroma — Osteoma — Sarcoma — Carcinoma. 

Acquired  deformities      .        . 543 

Twisted    nail — Ingrown    nail — Hallux   valgus — Hallux    rigidus — 
Hammer-toe — Flatfoot — Transverse  flatfoot — Painful  heel. 
Congenital  deformities:  Hypertrophy — Supernumerary  toes  .        .        .561 

SECTION   VIII 

MINOR  SURGICAL  TECHNIQUE 

Chapter  XX. — Operative  Technique 

Conditions  of  operation 563 

Asepsis — Operating  room — Preparation  of  patient — Hands  of  the 
operator — -Instruments — Solutions — Local  anesthesia. 

Treatment  of  the  wound 568 

Control  of  hemorrhage — Tying  a  ligature — Drainage — Sutures — - 
Dressings:  Dry  gauze;  cotton-collodion;  wet. 

Some  typical  operations 575 

Opening  an  abscess — Removal  of  a  tumor — Skin-grafting:  Thiersch 
method;  Wolfe  method — -Plastic  operations — Lumbar  puncture — 
Transfusion — Infusion — Venesection — Cupping — Leeching — Vacci- 
nation. 

Chapter  XXI. — The  Roller  Bandage 

General  principles 589 

Preparation  of  a  bandage — Application:  Anchoring;  spiral  reverse; 
overlapping  of  turns;  figure  of  eight;  the  spica;  amount  of  pressure; 
completion. 

Bandages  of  head , 595 

1 .  Horizontal  circular — 2.  Oblique  circular — 3.  Double  oblique  circu- 
lar— 4.  Crossed  circular — 5.  Knotted — 6.  Figure  of  eight — -7.  Single 
roller — 8.  Double  roller — 9.  Partial  recurrent — 10.  Figure  of  eight 
of  one  eye — 11.  Figure  of  eight  of  both  eyes — 12.  Four-tailed  of 
jaw — 43.  Barton's  of  jaw — 14.  Gibson's  of  jaw — 15.  Figure  of 
eight  of  forehead  and  chin. 

Bandages  of  the  neck  and  axilla,  alone  and  in  combination    .        .        .     613 
16.  Circular — 17.  Posterior  figure  of  eight  of  head  and  neck — 18. 
2 


xviii  CONTENTS 

PAGE 

Anterior  figure  of  eight  of  head  and  neck — 19.  Figure  of  eight  of 
neck  and  axilla— 20.  Figure  of  eight  of  both  axilla? — 21.  Oblique 
circular  of  neck  and  axilla — 22.  Complete,  of  neck — 23.  Complete, 
of  axilla — 24.  Anterior  figure  of  eight  of  neck  and  chest. 

Bandages  of  the  trunk 626 

25.  Anterior  figure  of  eight  of  chest — 26.  Posterior  figure  of  eight  of 
chest — 27.  Spiral  of  the  chest — 28.  Spica  of  one  breast — 29.  Spica 
of  both  breasts — 30.  Yelpeau's  figure  of  eight  of  chest  and  shoulder 
— 31.  Desault's  of  chest  and  shoulder — 32.  Descending  spiral  of 
abdomen — 33.  Many-tailed  of  abdomen. 

Bandages  of  the  upper  extremity 643 

34.  Ascending  spica  of  shoulder — 35.  Descending  spica  of  shoulder 
— 36.  Spiral  of  arm — 37.  Concentric  figure  of  eight  of  elbow — 38. 
Eccentric  figure  of  eight  of  elbow — 39.  Spiral  reverse  of  forearm — 
40.  Figure  of  eight  of  forearm — 41.  Figure  of  eight  of  hand — 42. 
Spiral  reverse  of  hand — 43.  Spica  of  thumb — 44.  Spiral  reverse  of 
finger — 45.  Figure  of  eight  of  finger — 46.  Gauntlet,  or  figure  of 
eight  of  fingers  and  wrist — 47.  Recurrent  of  finger. 

Bandages  of  the  lower  extremity 657 

48.  Ascending  spica  of  one  groin — 49.  Descending  spica  of  one 
gioin — 50.  Ascending  spica  of  both  groins — 51.  Descending  spica 
of  both  groins — 52.  Ascending  spica  of  buttock — 53.  Crossed 
perineal— -54.  Spiral  reverse  of  thigh — -55.  Concentric  figure  of 
eight  of  knee — 56.  Eccentric  figure  of  eight  of  knee — 57.  Figure  of 
eight  of  both  knees — 5S.  Figure  of  eight  of  the  leg — 59.  Spiral 
reverse  of  leg — 60.  Figure  of  eight  of  ankle — 61.  Figure  of  eight  of 
foot  and  leg — 62.  Eccentric  figure  of  eight  of  heel — 63.  Modified 
eccentric  figure  of  eight  of  heel — 64.  Spica  of  foot — 65.  Circular  of 
toe — 66.  Spica  of  great  toe — 67.  Complex  spica  of  great  toe — 68. 
Recurrent  of  stump. 

Chapter  NNII. — Surgical  Dressings 

Textile  materials 681 

Absorbent  cotton — Lamb's  wool — Gauze; — Gauze  sponges;  strips; 
bandages — Muslin — Flannel  —  Canton  flannel — Stockinette — Silk 
— Rubber — Crinoline — Gutta-percha  tissue — Oiled  muslin,  silk, 
and  paper. 

Ligatures  and  sutures 689 

Catgut:  Plain;  chromic — Kangaroo-tendon — Silk — Silkworm  gut — 
Horsehair — Cotton  and  linen  thread — Celluloid  thread — Silver  wire 

Drains 694 

Glass  and  metal  tubes — -Soft  rubber  tubes — Gutta-percha  drains — 
Cigarette  drains— Gauze  drains — Handkerchief  drains — Horse- 
hair drains. 

Splints 698 

Wood — Metal — Wire  netting. 

Gypsum  or  plaster  of  Paris 700 

Gypsum  bandages — Circular  splints — Cutting  a  fenestrum — 
Molded  splints — Reinforcing  a  splint — Gypsum  or  plaster  casts — 
Plaster  jackets. 


CONTENTS  xix 

Chapter  XXIII. — -General  Anesthesia  page 

General  remarks 714 

Underlying  principles — Confidence — Anesthesia  in  children — By- 
standers — ■  Physical  examination  —  Preparation  —  Position  —  Re- 
straint— -Place — Preliminary  medication — Induction — Respiration 
—Pulse — Signs  of  surgical  anesthesia. 

Complications  during  anesthesia 723 

Compressed  lips — Displaced  jaw — Tongue — Excitement — Saliva 
in  the  pharynx — Vomiting — Muscular  spasms — Cyanosis — Cessa- 
tion of  respiration — Irregular  heart  action — Oxygen  in  anesthesia. 

Post-anesthetic  conditions 731 

Recovery  from  anesthesia — Nausea  with  vomiting — Shock — Per- 
spiration— Death — Status  lymyhaticus — Acid  intoxication — Bron- 
.     chitis  and  pneumonia — Records. 

Anesthetics 739 

Nitrous-oxid  gas — Primary  or  induction  anesthesia  with  gas — 
Nitrous-oxid  gas  for  prolonged  anesthesia — Ether — Chloroform — 
Ethyl  chlorid  —  Somnoform  —  Mixed  anesthetics  —  Hypodermic 
anesthesia — Rectal  anesthesia — Spinal  analgesia — Choice  of  anes- 
thetic. 
Chapter  XXIV. — Additional  Surgical  Technique 

Operations  upon  blood-vessels 775 

Withdrawal  of  blood  for  examination — Direct  blood  transfusion — 
Injection  of  salvarsan. 

Operations  upon  nerves 782 

Injections  of  alcohol  for  neuralgia. 

Vaccine  therapy — Serum  therapy 787 

Index 793 


LIST  OF  ILLUSTRATIONS 


HEAD 

FIG.  PAGE 

1. — Hematoma  of  ear  from  a  blow 4 

2. — Hematoma  of  ear  from  a  blow,  three  weeks  previous   ....  5 

3. — Powder  grains  in  face  from  a  recent  explosion 7 

4. — Powder  grains  removed  by  scrubbing  with  a  stiff  brush      ...  8 

5. — Instruments  for  extracting  foreign  bodies  from  the  nose  and  ear       .  1 1 

6. — Division  of  Steno's  duct  by  a  razor  cut 16 

7. — Fracture  of  right  malar  bone  with  depression 18 

8. — Four-tailed  bandage  for  fracture  of  the  inferior  maxilla       ...  21 

9. — Necrosis  and  slough  of  skin  due  to  cellulitis 34 

10. — Abscess  of  the  lip 38 

11. — Alveolar  abscess  from  upper  incisor  tooth 40 

12. — Alveolar  abscess  from  upper  molar  teeth 41 

13. — Alveolar  abscess  from  upper  tooth,  secondary  in  lymphatic  gland    .  42 

14. — Recurrent  alveolar  abscess 43 

15. — Chronic  alveolar  abscess  with  sinus 44 

16. — Chronic  alveolar  abscess;  chronic  edema;  no  sinus        ....  45 

17. — Tumor  following  alveolar  abscess;  probably  malignant         ...  46 
18. — Sketch  of  the  normal  right  tympanic  membrane,  showing  the  correct 

site  for  incision 52 

19. — Angular  knife  for  incision  of  tympanic  membrane        ....  52 

20. — Chancre  of  lip,  of  nine  days'  duration 60 

21. — Chancre  of  lip,  of  three  weeks'  duration 60 

22/ — Chancre  of  cheek,  developing  in  burn  from  cigarette    ....  61 

23. — Chancre  of  cheek  with  a  granulating  ulcer 62 

24. — Papilloma  of  lip  due  to  syphilis 63 

25. — Tuberculosis  of  the  gum,  secondary  to  pulmonary  tuberculosis  .        .  65 

26. — Tense  sebaceous  cyst  of  forehead,  about  to  rupture      ....  67 

27. — Sebaceous  cyst  of  scalp,  skin  prepared  for  operation     ....  68 

28. — Sebaceous  cyst  of  scalp,  overlying  skin  divided  and  retracted   .        .  69 
29. — Sebaceous  cyst  of  scalp,  collapsed  redundant  skin  after  removal  of 

cyst 70 

30.: — Inflamed  sebaceous  cyst  behind  the  ear 70 

31. — Cyst  of  sublingual  gland — ranula 71 

32. — Dental  cyst,  mistaken  for  alveolar  abscess 73 

33. — Dermoid  cyst  of  the  nose 74 

34. — Dermoid  cyst  in  front  of  the  ear       . 75 

35. — Dermoid  cyst  behind  the  ear 75 

36. — Papilloma  of  skin  occurring  in  a  scar,  diagnosed  as  cancer          .        .  77 

sad 


XXII  LIST   OF   II. 1. 1  STRATIONS 

i :  PAGE 

;;7. — Lipoma  of  forehead 79 

38. — Fibrolipoma  of  auditory  canal 80 

39. — Pulsating  angioma  of  scalp;  congenital;  fully  distended       ...  82 

40. — Pulsating  angioma  of  scalp,  compressed 83 

'41. — Rosacea  hypertrophies  of  the  nose;  <>f  seven  years'  duration      .        .  84 

42. — Rosacea  hypertrophica  of  the  nose,  of  four  years' duration        .       .  85 

43. — Same  subject  as  Fig.  42,  side  view 85 

44. — Same  subject  as  Fig.  42,  alter  two  operations 86 

45. — Same  subject  as  Fig.  42,  after  two  operations,  side  view      ...  86 

46. — Instruments  lor  the  removal  of  the  tonsil 88 

47. — Instruments  for  the  removal  of  adenoids 90 

48. — Exostosis  of  jaw 91 

49. — Epithelioma  of  face  near  nose 93 

50. — Epithelioma  of  the  lip  developing  in  a  soft  wart  which  had  existed 

since  childhood 93 

51. — Same  subject  as  Fig.  50,  three  months  after  removal  of  the  tumor     .  !)  I 

52. — Epithelioma  of  the  nose,  recently  growing  rapidly        ....  95 

53. — Epithelioma  of  the  cheek  existing  two  years 96 

54. — Epithelioma  of  face 96 

55. — Epithelioma  of  the  scalp 97 

56. — Epithelioma  of  lip,  of  four  weeks'  duration 98 

57. — Epithelioma  of  the  tongue,  showing  milky  white  patches  of  leuco- 

plakia  and  papillomatous  growths 99 

58. — Longitudinal  section  of  the  epitheliomatous  tongue  in  the  median  line  99 

59. — Transverse  section  of  the  epitheliomatous  tongue          ....  100 

60. — Epithelioma  of  lower  lip,  of  one  year's  duration 101 

61. — Epithelioma  of  lower  lip,  showing  line  of  incisions  ....  102 
62. — Epithelioma  of  lower  lip,  showing  suture  after  excision  of  the  V- 

shaped  piece 102 

63. — Tumor  of  head,  extradural 105 

64. — Angiosarcoma  of  lower  jaw 105 

65. — Tumor  of  parotid  gland,  of  twelve  years'  duration        ....  106 

66. — Diagram  of  the  septum  of  the  nose 109 

67. — Scissors  for  the  amputation  of  the  uvula Ill 

68. — Harelip,  the  cleft,  not  entering  the  nostril 113 

69. — Harelip,  the  cleft  entering  the  nostril 113 

70. — Congenital  cleft  of  lower  lip 114 

71. — Cleft  of  lobe  of  auricle,  congenital 116 

72. — Deformity  of  ear,  congenital 116 


NECK 

73. — Instruments  for  tracheotomy 121 

74. — Carbuncle  of  neck 128 

75. — Carbuncle  of  neck,  of  four  weeks'  duration,  incised  three  times          .  J 29 
76. — Same  patient  as  shown  in  Fig.  75,  eleven  weeks  later  .        .        .        .129 

77. — Abscess  of  neck,  secondary  to  pediculosis  capitis 130 

78. — Abscess  under  sternomastoid  muscle,  probably  tubercular  .        .        .  131 

79. — The  primary  lesion  of  anthrax 132 

80. — Thyreoglossal  cyst;  operation;  recurrence 136 


LIST  OF  ILLUSTRATIONS  xxiii 

FIG.  PAGE 

81. — Simple  lipoma  of  neck,  of  two  years' duration       .        .        ,        .        .138 

82. — Diffuse  lipoma  of  neck,  bilateral 138 

83. — Fibroma  of  the  neck  of  nine  years'  duration 139 

84. — The  tumor  of  Fig.  83  after  removal 140 

85. — Single  cyst  of  thyroid 146 

86. — Goiter  with  exophthalmos 146 

87. — Cicatricial  contractions  following  burn  of  the  neck       ....  148 

88. — Torticollis  (wryneck)  of  right  side  of  moderate  degree          .        .        .  149 

89. — Extreme  degree  of  torticollis  (wryneck) 150 

90. — Back  view  of  patient,  shown  in  Fig.  89 150 


TRUNK 

91. — Large  hematoma  of  mammary  region,  five  weeks  after  a  blow   .        .  153 

92. — Strips  of  adhesive  plaster,  gridiron  pattern,  for  sprain  of  back  .        .  160 

93. — Strips  of  plaster  applied  diagonally,  for  sprain  of  back         .        .        .  160 

94. — Tests  for  injury  of  the  spine.     Forward  flexion      .        .        .        .        .  161 

95. — Tests  for  injury  of  the  spine.     Backward  flexion 161 

96. — Tests  for  injury  of  the  spine.     Lateral  flexion 162 

97. — Tests  for  injury  of  the  spine.     Rotation 162 

98. — Fracture  of  left  clavicle,  usual  situation 163 

99. — Sayre  dressing  for  fracture  of  clavicle.     Rear  view       ....  165 
100. — Sayre  dressing  for  fracture  of  clavicle.     Front  view      ....  165 
101. — Multiple  burns  of  body  of  five  days'  duration,  produced  by  spatter- 
ing liquid  iron 170 

102. — Instruments  for  drainage  of  chest  in  empyema 176 

103. — Fibrolipomata  of  the  back  of  five  years'  duration  .        .        .        .185 

104. — Lipoma  of  back  of  two  years'  duration 186 

105. — Lipoma  shown  in  Fig.  104  after  removal 187 

106. — Epithelioma  of  back  at  an  early  stage 190 

107. — Cross-section  of  tumor  shown  in  Fig.  106 191 

108. — Melanosarcoma  of  lower  abdomen  of  four  months'  duration,  growing 

from  a  mole  or  soft  wart 191 

109. — Cyst  under  scapula  of  one  week's  duration 192 

110. — Removal  of  displaced  coccyx 193 

111. — Dorsal  hernia 196 

112. — Method  of  holding  a  trocar 200 


MALE   GENITALS 

113. — Edema  of  penis  and  scrotum  from  mercuric  ointment  .  211 

114. — Abscess  of  scrotum  of  five  days'  duration 212 

115, — A  good  type  of  steel  sound 218 

116. — Eczema  of  penis  of  four  months'  duration 223 

117. — Primary  lesion  of  syphilis  in  an  aged  patient 225 

118. — Unilateral  syphilitic  orchitis 227 

119. — Gumma  of  testicle  with  ulceration 228 

120. — Cyst  of  prepuce;  left  inguinal  hernia 231 

121. — Cyst  of  prepuce  after  circumcision 232 

122, — Squamous  celled  carcinoma  of  penis 233 


xxiv  LIST  OF    ILLUSTRATIONS 

FIT..  PAGE 

123. — Hydrocele  of  four  months'  duration .       .......  237 

124. — Hydrocele  of  ten  years' duration;  never  treated 237 

125. — Varicocele  of  moderate  degree 242 

126. — Varicocele  of  fourteen  years'  duration 243 

127. — Tight  phimosis;  congenital 245 

128. — Operation  for  phimosis.     Dorsal  and  ventral  incisions         .        .        .  248 

129. — Operation  for  phimosis.     All  sutures  inserted 249 


FEMALE  GENITALS 

130. — Urethroscope  for  examining  female  urethra 259 

131. — Multiple  syphilitic  tumors  of  vulva 268 

132. — Syphilitic  condyloma  of  thigh  near  the  vulva 269 

133. — Pessaries  for  prolapse  of  uterus 276 

134. — Hard  rubber  plugs  for  use  in  stenosis  of  the  cervix       ....  279 

ANUS   AND   RECTUM 

135. — Suitable  rectal  speculum  for  office  examination 282 

136. — Bivalve  rectal  speculum 283 

137. — Small  superficial  ischiorectal  abscess 292 

138. — A  larger  and  deeper  ischiorectal  abscess 293 

139. — Fistula  accompanying  a  syphilitic  stricture  of  the  rectum   .        .        .  296 

140. — Syphilitic  condylomata  about  anus  of  a  young  male     ....  300 

141. — Venereal  warts  about  the  anus  of  a  man 307 

142. — Acute  external  hemorrhoid  of  one  week's  duration        ....  309 

143. — Internal  hemorrhoids  of  sixteen  years'  duration 312 

ARM   AND   HAND 

144. — Hematoma  under  nail 326 

145. — Incision  for  hematoma  under  nail 326 

146. — Diagram  to  show  position  of  radial  and  ulnar  arteries          .        .      •  .  328 

147. — Test  for  division  of  the  profundus  tendon 330 

148. — Test  for  division  of  the  sublimis  tendon 330 

149. — Traumatic  ulcers  of  the  hand 331 

150. — Tendon  suture.     (A)  Mattress  stitch.     (B)  Simple  stitch    .        .        .  333 

151. — Tendon  suture,  one  method  of  elongation  of  a  tendon  ....  333 

152. — Tendon  suture,  a  long  silk  stitch  being  left  in  place      ....  334 

153. — Nerve  suture 335 

154. — Sprain  of  finger  with  serous  effusion  in  joint 339 

155. — Plaster  strapping  for  sprain  of  the  thumb 340 

156. — Diagram  to  show  the  relations  of  the  extensor  tendons  and  the  radius  343 

157. — Aspiration  of  shoulder-joint  for  synovitis 345 

158. — Acute  olecranon  bursitis 346 

159. — Dislocation  of  thumb  of  seven  years'  duration 349 

16Q. — Radiograph  showing  the  bones  seven  years  after  a  dislocation  of  the 

thumb 349 

161. — Radiograph  of  forward  dislocation  of  the  head  of  the  radius  and 

fracture  of  the  ulna 352 


LIST   OF   ILLUSTRATIONS  XXV 

FIG.  PAGE 

162. — Radiograph  showing  backward  dislocation  of  both  radius  and  ulna, 

about  five  months'  duration 353 

163. — Overextension  of  adult  thumb 356 

164. — Posterior  dislocation  of  finger  with  radiograph 357 

165. — Reduction  of  dislocated  finger  by  operation 358 

166. — Lateral  dislocation  of  finger,  due  to  bite  of  horse 359 

167. — Radiograph  of  lateral  dislocation  of  finger 359 

168.— Drop-finger 361 

169. — Traumatic  drop-finger  of  three  months'  duration 361 

170. — Radiograph  of  traumatic  drop-finger,  anteroposterior  view         .        .  362 

171. — Radiograph  of  traumatic  drop-finger,  lateral  view        ....  362 

172. — Radiograph  of  fracture  of  the  neck  of  the  radius 376 

173. — Radiograph  of  fracture  of  neck  of  radius,  side  view      ....  377 

174. — Molded  gypsum  splints  for  fracture  of  the  lower  end  of  the  radius     .  382 

175. — Molded  gypsum  splints  applied 383 

176. — Old  fracture  of  radius  (Colles')  with  marked  deformity        .        .        .  384 

177. — Fracture  of  second  right  metacarpal 385 

178. — Compound  fracture  of  the  forefinger 387 

179. — Injuries  of  the  hand  from  contact  with  a  buzz-saw       ....  388 

180. — Amputation  through  the  metacarpal  phalangeal  joint          .        .        .  389 

181. — Amputation  of  finger  with  the  head  of  the  metacarpal         .        .        .  390 

182. — Same  hand  as  in  Fig.  181;  dorsal  surface        .        .        .        .        .        .  390 

183. — Amputation  of  two  central  fingers  with  the  metacarpals      .        .        .  391 
184. — Same  hand  as  in  Fig.  183;  dorsal  surface        .        .        .        .                .391 

185. — Partial  gangrene  of  finger  due  to  carbolic  acid 395 

186. — Carbolic  gangrene  of  distal  half  of  finger         ......  396 

187. — Carbolic  gangrene  of  thumb,  complicated  by  cellulitis          .        .        .  397 

188. — Recovery  following  carbolic  gangrene  of  thumb     .        .        .        .        .  398 

189. — Anatomical  tubercle 400 

190. — Erysipeloid  dermatitis  in  wound  of  hand  of  seven  days'  duration      .  401 

191. — Cellulitis  of  finger  with  abscess          .                402 

192. — Moist  gangrene  of  finger,  following  cellulitis 403 

193. — Boil  of  wrist  with  secondary  pimples 405 

194. — Section  of  the  terminal  segment  of  finger  to  show  various  sites  of 

suppuration 406 

195. — Abscess  of  tip  of  thumb  with  spontaneous  rupture        ....  406 

196. — Acute  paronychia  of  three  weeks'  duration 408 

197. — Acute  paronychia,  ten  days  after  removal  of  old  nail  ....  409 

198. — Chronic  paronychia  of  four  months'  duration 410 

199. — Abscess  in  tendon  sheath  of  thumb  from  a  splinter  .        .        .411 

200. — Suppuration  in  index-finger  extending  into  the  palm    ....  414 

201. — Same  subject  as  Fig.  200.     Posterior  view 415 

202. — Same  subject  as  Fig.  200.     Temperature  chart 416 

203. — Same  subject  as  Fig.  200.     Ultimate  result 416 

204. — Suppuration  in  tendon  sheath  of  four  weeks'  duration         .        .        .  420 

205. — Same  subject  as  Fig.  204.     Dorsal  view 420 

206. — Cicatricial  contraction  of  finger  following  suppuration         .        .        .  421 

207. — Loss  of  extensor  tendons  from  suppuration .  422 

208. — Suppuration  in  joint  following  penetration  by  splinter         .        .        .  422 

209. — Suppurative  arthritis  and  loss  of  metacarpal         .....  423 


XXVI 


LIST    OF    ILl.l'STKATlOXS 


210. — Radiograph  of  a  hand  showing  result  of  suppurative  arthritis 
211. — Tin  splint  for  use  in  suppurative  arthritis      .... 

212. — Suppurative  olecranon  bursitis 

213. — Infected  wound  of  finger  with  secondary  lymphatic  abscess 

214. — Superficial  axillary  abscess  from  infection  about  hairs 

215. — Primary  lesion  of  syphilis  developing  in  the  finger 

216. — Syphilitic  ulcer  of  the  hand  of  four  months'  duration 

217. — Same  hand  as  Fig.  216,  after  four  weeks  of  treatment 

218. — Chronic  syphilitic  inflammation  of  hand  with  sinus 

219. — Syphilis  of  hand  with  amputation  of  a  finger 

220. — Tuberculosis  of  flexor  tendon  sheaths  of  hand 

221. — Tenosynovitis,  probably  tubercular 

222. — Diagram  to  show  the  range  of  motion  in  a  joint    . 

223. — Tuberculosis  of  the  wrist  with  sinus 

224. — Ganglion  of  wrist  of  five  years'  duration 

225. — Ganglion  of  wrist,  lateral  view 

226. — Ganglion  of  the  wrist,  the  skin  incised  and  dissected 
227. — Ganglion  of  the  wrist,  showing  ligation  of  the  sac 
228. — Nevus  of  hand  of  seven  years'  duration  . 
229. — Extensive  varices  of  the  arm  and  hand   . 

230. — Inclusion  cyst  of  palm 

231. — Simple  lipoma  of  arm 

232. — Fibrosarcoma  of  finger,  of  six  years'  duration 

233. — Radiograph  of  fibrosarcoma  of  finger  showing  normal 

234. — Fibroma  of  hand 

235. — Fibrolipoma  of  wrist — papilloma      .... 

236. — Osteoma  of  finger 

237. — Radiograph  of  osteoma  of  finger,  showing  affected  bone 

238. — Fibrolipoma  of  finger 

239. — Radiograph  of  the  same  hand,  showing  normal  bones 

240. — Granuloma  of  finger 

241.— Old  wart  of  index-finger 

242. — Metastatic  carcinoma  of  the  bones  of  the  hand 

243. — Same  patient  as  shown  in  Fig.  242,  showing  the  site 

tumor,  and  numerous  cutaneous  metastases 
244. — Spindle-cell  sarcoma  of  hand  of  ten  years'  duration 
245. — Cicatricial  contractions  from  burns  . 
246. — A  quick  method  of  lengthening  a  tendon  without  suti 
247. — Dupuytren's  contraction  of  six  months'  duration 
248. — Radiograph  of  the  webbed  hand  of  an  infant 

249. — Web-fingers  of  a  child 

250. — Result  after  operation  for  web-fingers      . 

251. — Supernumerary  thumb 

252. — Radiograph  of  supernumerary  thumb 


of  the  or 


'iiial 


LOWER   EXTREMITY 

253. — Hematoma  of  foot  produced  by  turning  the  ankle        ....  472 

254. — Hematoma  under  left  great  toe-nail 472 

255. — Subperiosteal  hematoma  of  the  head  of  the  tibia 473 


LIST  OF  ILLUSTRATIONS  xxvn 

Fia.  pa<;  e 

256. — Prepatellar  bursitis 477 

257. — Suppuration  in  prepatellar  bursa,  with  rupture  of  the  skin          .        .  478 

258. — Chronic  prepatellar  bursitis;  the  bursa  laid  open 479 

259. — Operation  for  chronic  prepatellar  bursitis 480 

260. — Inflammation  of  the  outer  metatarsophalangeal  bursa          .        .        .  482 

261. — Floating  cartilage  from  the  knee-joint '       .  485 

262. — Incision  for  removal  of  floating  cartilage  from  the  knee       .        .        .  486 

263. — Relation  of  the  great  trochanter  to  the  ilium 488 

264. — Demonstration  of  floating  patella 490 

265. — -Strapping  with  adhesive  plaster  for  sprain  of  the  knee         .        .        .  493 

266. — Strapping  a  sprained  ankle  with  adhesive  plaster          ....  495 

267. — Radiograph  showing  fracture  of  the  great  trochanter  ....  498 

268. — Application  of  adhesive  plaster  for  fracture  of  patella  ....  499 
269. — Correct  method  of  holding  foot  and  leg  during  the  application  of  a 

splint — in  cases  of  malleolar  fracture 505 

270. — Strap  splints  for  fracture  of  malleoli — in  position          ....  506 

271. — Strap  splints  for  fracture  of  malleoli — removed 506 

272. — Frost-bite  of  both  feet  three  weeks  after  injury 511 

273. — Frost-bite  of  both  feet;  the  results  after  treatment       ....  512 

274. — Burns  of  the  back  of  the  leg  and  thigh 513 

275. — Gangrene  of  toe — possibly  from  frost-bite 514 

276. — Abscess  in  front  of  the  knee  from  infection  on  the  skin        .        .        .  517 

277. — Ulcers  of  the  leg  from  pediculosis  and  scratching 518 

278.— Ulcer  of  the  leg 519 

279. — Chronic  ulcer  almost  encircling  the  leg 520 

280. — Ulcer  of  leg,  spread  by  a  vaseline  dressing 522 

281. — Chronic  ulcer  of  the  leg  with  proliferation 525 

282. — Ulcers  of  leg  due  to  syphilis 527 

283. — Traumatic  ulcer  of  the  leg  exposing  the  tibia 529 

284. — Perforating  ulcers  of  the  foot 530 

285. — Perforating  ulcers  of  the  toes  of  two  years'  duration    ....  531 

286. — Dorsal  view  of  the  same  patient  as  shown  in  Fig.  285  ....  531 

287. — Osteoma  of  the  tibia 541 

288. — Osteoma  under  the  nail  of  the  great  toe 541 

289. — Sarcoma  of  the  great  toe  from  injury 543 

290. — Carcinoma  of  the  leg  developing  in  an  old  ulcer 543 

291. — Twisted  nails 544 

292. — Longitudinal  and  transverse  sections  of  great  toe  showing  the  nail, 

matrix,  phalanx,  and  joint 545 

293. — Ingrown  nail 546 

294. — Drawings  to  illustrate  operation  for  ingrown  nail 547 

295. — Great  toe  after  operation  for  ingrown  nail 548 

296. — Great  toe  ten  days  after  operation  for  ingrown  nail       ....  549 

297.— Hallux  valgus 550 

298. — Hallux  valgus  with  hypertrophy  of  the  head  of  the  metatarsal,  sup- 
purative bursitis  and  synovitis 551 

299. — Lateral  splint  for  holding  the  toe  after  operation  for  hallux  valgus   .  553 
300. — Interwoven  adhesive  strips  for  correcting  the  deformity  of  hammer- 
toe after  operation 555 

301. — Testing  the  degree  of  rigidity  in  flatfoot 557 


XXV111 


LIST  OF   ILLUSTRATIONS 


FIG. 

302. — Markedly  rigid  flatfeet  put  up  in  corrected  position 
303. — Congenital  hypertrophy  of  the  second  toe 


PAGE 

559 
561 


OPERATIVE  TECHNIQUE 

304. — Injection  of  cocain  for  local  anesthesia 

305. — Method  of  tying  ligatures 

300. — Drains  for  clean  and  suppurating  wounds       .... 

307. — Silk  and  horsehair  in  straight  and  curved  skin  needles 

308. — Lumbar  puncture:  diagrammatic  sagittal  section  of  the  spine 

309. — Lumbar  puncture:  transverse  section  of  the  spine 

310. — Lumbar  puncture:  the  lumbar  spine  as  seen  from  behind    . 


567 
569 
571 
573 
581 
582 
583 


ROLLER   BANDAGE 

311. — Rolling  a  bandage  on  a  small  machine    . 

312. — Making  a  reverse  in  a  spiral  bandage 

313. — Making  a  figure  of  eight  turn  about  the  forearm 

314. — Fastening  a  bandage  by  splitting  the  end  and  tying 

315. — Occipitofrontal  bandage  of  the  head 

316. — Oblique  circular  bandage  of  the  head 

317. — Double  oblique  circular  bandage  of  the  head 

318. — The  crossed  circular  bandage     . 

319. — Knotted  bandage  of  the  head    . 

320. — Figure  of  eight  bandage  of  the  head 

321. — Single  roller  bandage  of  the  head 

322. — Single  roller  bandage  of  the  head  completed 

323. — Double  roller  bandage  of  the  head    . 

324. — Double  roller  bandage  of  the  head  completed 

325. — Partial  recurrent  bandage  of  the  head     . 

326. — Figure  of  eight  bandage  of  one  eye  . 

327. — Figure  of  eight  bandage  of  both  eyes 

328. — Four-tailed  bandage  of  the  jaw 

329. — Barton's  bandage,  with  first  layer  completed 

330. — Gibson's  bandage  for  the  lower  jaw 

331. — Gibson's  bandage  completed 

332. — Figure  of  eight  bandage  of  the  forehead  and  chin 

333. — Circular  bandage  of  neck 

334. — Posterior  figure  of  eight  bandage  of  head  and  neck 

335. — Anterior  figure  of  eight  bandage  of  the  head  and  neck 

336. — Figure  of  eight  bandage  of  neck  and  axilla 

337. — Figure  of  eight  bandage  of  neck  and  axilla  with  additonal 

338. — Figure  of  eight  bandage  of  both  axillae    . 

339. — Oblique  circular  bandage  of  the  neck  and  axilla 

340. — Complete  bandage  of  the  neck  at  an  early  stage 

341. — Complete  bandage  of  the  neck  in  skeleton  form 

342. — Complete  bandage  of  the  axilla,  composed  of  six  parts 

343. — Anterior  figure  of  eight  bandage  of  the  neck  and  chest 

344. — Anterior  figure  of  eight  bandage  of  chest 

345. — Posterior  figure  of  eight  bandage  of  chest 


turns 


589 
591 
592 
594 
595 
596 
597 
598 
599 
600 
601 

602 

604 
604 
605 
606 
608 
609 
610 
611 
612 
612 
614 
614 
615 
616 
617 
618 
619 
621 
622 
624 
625 
627 
628 


LIST  OF   ILLUSTRATIONS  XXIX 

FIG.  PAGE 

346. — Descending  spiral  bandage  of  the  chest 629 

347. — Descending  spiral  bandage  of  the  chest  completed        ....  630 

348. — Spica  bandage  of  one  breast 631 

349. — Spica  bandage  of  one  breast  completed 632 

350. — Spica  bandage  of  both  breasts 633 

351. — Spica  bandage  of  both  breasts  nearing  completion        ....  634 

352. — Velpeau's  bandage,  showing  the  first  turn 635 

353. — Velpeau's  bandage  at  the  beginning  of  second  oblique  turn         .        .  636 

354. — Velpeau's  bandage  nearly  completed 637 

355. — Desault's  bandage,  showing  the  spiral  of  the  chest        ....  638 

356. — Desault's  bandage,  showing  the  fixation  of  the  arm  to  the  chest        .  638 

357. — Desault's  bandage,  showing  the  application  of  the  third  roller   .        .  639 

358. — Desault's  bandage  completed    .        .        . 640 

359. — Descending  spiral  bandage  of  abdomen 641 

360. — Posterior  view  of  many  tailed  bandage  of  abdomen      ....  642 

361. — Anterior  view  of  many  tailed  bandage  of  abdomen       ....  642 

362. — Ascending  spica  bandage  of  the  shoulder        .        .        .        .        .        .  644 

363. — Descending  spica  bandage  of  shoulder 645 

364. — Ascending  spiral  bandage  of  the  upper  arm 645 

365. — Concentric  figure  of  eight  bandage  of  the  elbow 646 

366. — Eccentric  figure  of  eight  bandage  of  the  elbow 647 

367. — Spiral  reverse  bandage  of  forearm    . 648 

368. — Figure  of  eight  bandage  of  forearm  in  application         ....  649 

369. — Figure  of  eight  bandage  of  forearm  completed 649 

370. — Figure  of  eight  bandage  of  the  hand 650 

371. — Spiral  reverse  bandage  of  the  hand 651 

372. — Spica  bandage  of  the  thumb      .        .        .        » 652 

373. — Spiral  reverse  bandage  of  the  finger 653 

374. — Figure  of  eight  bandage  of  finger 654 

375. — Figure  of  eight  bandage  of  the  fingers  and  hand,  the  "  gauntlet "      .  655 

376. — Recurrent  bandage  of  the  finger 656 

377. — Recurrent  bandage  of  the  finger  at  a  later  stage 657 

378. — Ascending  spica  bandage  of  one  groin 658 

379. — Ascending  spica  bandage  of  one  groin  completed 659 

380. — Ascending  spica  bandage  of  both  groins 660 

381. — Ascending  spica  bandage  of  the  buttock 661 

382. — Ascending  spica  bandage  of  the  buttock  completed      ....  662 

383. — Crossed  bandage  of  the  perineum  in  application 663 

384. — Crossed  bandage  of  the  perineum  at  a  later  stage          ....  664 

385. — Spiral  reverse  bandage  of  the  thigh 665 

386. — Spiral  reverse  bandage  of  thigh  completed 665 

387. — Concentric  figure  of  eight  bandage  of  knee 666 

388. — Concentric  figure  of  eight  bandage  of  knee  completed  ....  667 

389. — Eccentric  figure  of  eight  bandage  of  knee 668 

390. — Figure  of  eight  bandage  of  both  knees 669 

391. — Figure  of  eight  bandage  of  the  leg 670 

392. — Spiral  reverse  bandage  of  the  leg      .......  671 

393. — Figure  of  eight  bandage  of  the  ankle 672 

394. — Figure  of  eight  bandage  of  foot  and  leg 673 

395. — Figure  of  eight  bandage  of  foot  and  leg,  at  a  later  stage     .        .        .  673 


XXX 


LIST  OF  ILLUSTRATIONS 


FIG.  PAGE 

396. — Figure  of  eight  bandage  of  the  foot  and  le^  completed         .       .       .  674 

397. — Eccentric  figure  of  eight  bandage  of  heel 675 

39S. — Modified  eccentric  figure  of  eight  bandage  of  heel          ....  (>7t> 

399. — Spica  bandage  of  foot 677 

400. — Spica  bandage  of  the  great  toe 678 

401. — Complex  spica  bandage  of  the  great  toe 679 


SURGICAL  DRESSINGS 

402. — Two  yards  of  gauze  cut  and  folded  to  make  twenty-four  gauze  sponges 

403. — Angular  splint  made  from  wire  netting    . 

404. — Making  gypsum  bandages  from  crinoline 

405. — Making  a  "dart"  in  a  gypsum  bandage 

406. — Making  a  cast  of  a  foot  in  gypsum  . 

407. — Cast  of  foot  in  gypsum:  the  mold  removed 


684 
699 
702 
704 
711 
712 


GENERAL  ANESTHESIA 

408.— Wooden  wedge  for  prying  open  the  jaw 722 

409. — Two  types  of  mouth  gag 723 

410. — Suction  apparatus  to  keep  throat  free  from  blood  and  saliva      .        .  726 

411. — Chloroform  may  be  administered  with  smelling  salts    ....  729 

412. — Simple  apparatus  for  giving  nitrous-oxid  gas 741 

413. — Gwathmey's  apparatus  for  giving  warmed  nitrous-oxid  gas  and  oxygen  745 
414. — Gas-oxygen  apparatus  with  attachments  for  four  cylinders  on  a  foot 

plate   .  746 

415. — Apparatus  for  giving  gas  and  ether,  or  ether  by  the  closed  or  open 

method ■ 751 

416. — Junker's  apparatus  for  giving  chloroform  vapor  attached  to  a  hollow 

Esmarch  mask 756 

417. — Gwathmey's  three-bottle  modification  of  Junker's  apparatus  for  giv- 
ing warm  ether  or  chloroform  vapor 757 

418. — Gwathmey's  apparatus  turned  upside  down  and  the  bottles  removed  .  758 

419. — Alcock's  apparatus  for  giving  a  known  percentage  of  chloroform  vapor  759 

420. — Dubois's  apparatus  for  giving  known  percentages  of  chloroform  vapor  759 

421. — Miller's  apparatus  for  vapor  anesthesia 773 


ADDITIONAL  SURGICAL  TECHNIQUE 

422. — Withdrawal  of  blood  from  a  vein  for  examination 
423. — Correct  position  of  the  needle  in  the  vein 
424. — Radial  artery  exposed  and  divided    . 

425. — Cephalic  vein  exposed 

426. — Gangrene  following  injection  of  neosalvarsan 
427. — Simple  apparatus  for  the  injection  of  salvarsan 
428. — Syringe,  stylet  and  needle  for  trifacial  injection 
429. — Needle  punctures  in  relation  to  the  bones  of  the  face 
430. — Injection  of  the  superior  maxillary  nerve,  side  view 
431. — Injection  of  the  superior  maxillary  nerve,  front  view 
432*. — Injection  of  the  inferior  maxillary  nerve,  side  view 
433. — Injection  of  the  inferior  maxillary  nerve,  front  view 


775 
776 
778 
779 
780 
781 
782 
783 
784 
784 
786 
786 


SECTION   I 

AFFECTIONS   OF   THE   HEAD 


CHAPTEE    I 
INJURIES   OF  THE   HEAD 

General  Considerations. — It  is  sometimes  difficult  to  deter- 
mine the  extent  of  an  injury  to  the  head  either  from  the  history 
of  the  accident  or  from  the  symptoms.  The  following  two  cases 
from  the  author's  experience  will  illustrate  this  fact : 

A  girl  fell  backward  down  some  stone  steps,  striking  her  head 
on  the  edge  of  one  of  them.  Blood  flowed  freely  from  a  wound 
in  the  scalp,  and  she  walked  to  the  hospital  to  have  it  dressed. 
There  was  no  shock,  nor  any  other  symptom  indicating  that  she 
had  suffered  serious  injury,  and  yet  retraction  of  the  edges  of  the 
wound  showed  that  there  was  a  compound  depressed  fracture  of 
the  skull. 

A  man  of  middle  age,  pushed  by  a  horse,  fell  against  a  sloping 
bank  of  earth.  He  was  apparently  uninjured  except  for  an  insig- 
nificant contusion  of  the  head.  Yet  subsequent  events  showed  that 
this  slight  accident  had  ruptured  a  blood-vessel  within  the  skull, 
as  a  result  of  which,  many  days  afterward,  the  first  symptoms 
of  paralysis  developed  and  progressed  to  complete  unconsciousness. 

Such  cases  are  a  warning  against  a  hasty  diagnosis  in  head 
injuries.  Every  patient  whose  head  has  been  injured  should  be 
carefully  examined,  and  kept  under  observation  for  two  or  three 
days,  as  otherwise  serious  complications  are  likely  to  be  over- 
looked. This  is  especially  important  if  no  clear  history  of  the 
accident  can  be  obtained,  either  because  the  patient  is  suffering 
from  intoxication  or  for  any  other  reason. 

Contusions.  —  The  scalp  is  firm  and  well  protected  by  hair 
from  external  injury.  It  is  loosely  attached  to  the  skull,  but  the 
absence  of  fatty  tissue  between  it  and  the  bone  makes  it  more 

1 


2  INJURIES  OP  THE  HEAD 

liable  to  suffer  in  the  case  of  a  sharp  blow.  A  contusion  of  the 
scalp  may  or  may  not  be  accompanied  by  a  great  deal  of  edema. 
If  the  swelling  is  discrete  and  evenly  curved  it  is  usually  due  to 
the  pouring  out  of  blood  underneath  the  scalp,  a  hematoma  (p.  2). 
The  eyelids,  nose,  and  lips  are  all  frequently  the  seat  of  contusion, 
with  marked  ecchymosis. 

Treatment. — If  the  patient  is  seen  soon  after  the  accident, 
very  hot,  wet  compresses  (p.  7)  should  be  applied  and  bandaged 
in  place  with  moderate  pressure  in  order  to  relieve  pain  and  pre- 
vent edema  and  hemorrhage.  Later,  a  wet  dressing  of  acetate 
of  aluminum,  four  per  cent  solution,  may  be  applied  to  prevent 
infection  and  facilitate  recovery.  The  hair,  even  of  a  man,  should 
not  be  needlessly  sacrificed.  In  many  cases  a  patient  is  mortified 
by  the  appearance  of  a  black  eye,  and  desires  to  have  the  normal 
color  of  the  skin  restored  as  quickly  as  possible.  The  hot,  moist 
applications  are  of  benefit,  and  in  a  day  or  two  they  should  be  fol- 
lowed by  very  gentle  massage  in  the  direction  of  the  lymph  cur- 
rent, for  this  will  facilitate  the  absorption  of  the  extravasated 
blood.  Considerable  improvement  in  appearance  may  be  obtained 
by  painting  over  the  blackened  area  with  theatrical  face  paint  or 
with  oxid  of  zinc  ointment.  If  the  latter  is  used  most  of  it  should 
be  wiped  off  and  a  little  face  powder  dusted  over  it  to  remove  the 
shiny,  greasy  appearance  which  the  ointment  causes. 

Subconjunctival  Ecchymosis. — Blows  upon  the  eye  may  be  fol- 
lowed by  an  accumulation  of  blood  beneath  the  conjunctiva,  either 
of  an  eyelid  or  of  the  eyeball,  frequently  extending  as  far  as 
the  iris.  Such  a  hemorrhage,  due  to  rupture  of  a  small  blood- 
vessel, also  occurs  as  a  result  of  violent  coughing  or  straining,  espe- 
cially in  persons  past  middle  life.  It  is  also  a  symptom  of  frac- 
ture of  the  skull,  in  which  case  the  blood  trickles  through  a  wall 
of  the  orbit  and  collects  beneath  the  conjunctiva.  Blood  beneath 
the  conjunctiva  of  the  eyeball  is  so  freely  supplied  with  oxygen 
that  it  remains  a  bright  red. 

The  treatment  for  this  ecchymosis  is  similar  to  that  already 
given  for  contusions  of  the  face.  It  is  only  fair  to  state  that  treat- 
ment has  little  effect  in  hastening  the  resorption  of  the  extrava- 
sated blood,  which  usually  requires  from  ten  days  to  two  weeks. 

Hematoma. — Hemorrhage  occurring  beneath  the  scalp  or  be- 
neath the  periosteum,  sufficiently  free  to  produce  a  hematoma,  is 


HEMATOMA  3 

most  common  at  those  points  at  which  the  scalp  is  most  exposed 
to  blows,  viz.,  over  the  parietal,  frontal,  and  occipital  bones,  about 
where  a  man's  hat  touches  his  head.  The  surface  of  a  hematoma 
is  even  and  rounded.  If  small,  the  swelling  rises  more  sharply 
from  the  surrounding  surface  than  if  extensive.  Edema  of  the 
skin  may  be  slight  or  wholly  wanting.  Fluctuation  can  usually 
be  obtained.  The  overlying  skin  may  be  discolored  by  an  accom- 
panying contusion,  but  even  if  this  is  absent  the  hematoma  will 
have  a  bluish  look,  due  to  the  underlying  blood.  Absorption  of 
so  large  a  quantity  of  blood  takes  place  very  slowly,  but  the  scalp 
is  so  abundantly  supplied  with  blood-vessels  that  necrosis  of  the 
skin  rarely  follows.  However,  the  time  of  recovery  will  be  much 
shortened  by  removal  of  the  effused  blood.  Suppuration  is  an 
occasional  complication  in  both  operated  and  non-operated  patients. 

Treatment. — Removal  of  the  effused  blood  may  be  accom- 
plished by  aspiration  if  the  contents  are  sufficiently ;  fluid,  or  the 
fluid  and  clotted  blood  may  be  turned  out  through  a  small  incision. 
The  head  should  be  prepared  by  a  careful  washing  with  hot  water 
and  soap,  and  then  with  alcohol.  If  an  incision  is  to  be  made  it 
is  better  to  shave  a  small  area,  but  if  sufficient  care  is  given  to 
cleansing  the  scalp  and  hair  in  the  vicinity,  primary  union  may 
be  obtained  without  this.  A  scalpel,  clamps,  two  small  hooked 
retractors,  thumb-forceps,  and  scissors  are  the  only  instruments 
needed.  They  should  be  boiled  before  using.  The  skin  is  divided, 
one  side  of  the  wound  is  elevated  with  a  retractor  or  with  for- 
ceps, and  the  clotted  blood  is  thoroughly  wiped  out  with  pieces  of 
absorbent  cotton  wrung  out  in  weak  bichloMe  of  mercury  solu- 
tion (1:  5,000).  The  fingers  of  the  operator1,  should  not  come  in 
contact  with  the  wound.  The  edges  of  the  incision  should  then  be 
drawn  together  with  sutures  of  fine  black  silk  or  horsehair,  and  a 
firm  dressing  of  dry,  sterile  gauze  applied  to  keep  the  involved  tis- 
sue planes  in  contact  and  to  prevent  exudation.  A  similar  dressing 
should  be  applied  after  aspiration.  The  dressing  should  be 
changed  on  the  following  day  and  the  pressure  kept  up  for  several 
days.     The  blood  in  a  recent  hematoma  is  not  easily  aspirated. 

Whether  or  not  drainage  is  required  will  depend  upon  circum- 
stances. A  folded  gutta-percha  drain,  if  removed  in  two  days,  does 
not  materially  delay  union,  and  leaves  no  scar.  Such  a  drain 
should  be  inserted  at  the  time  of  operation,  if  it  seems  likely  that 


INJURIES  OF  THE   HEAD 


the  blood  will  reaccumulate.  It  should  certainly  be  inserted  at 
the  first  dressing,  if  the  wound  was  not  drained  at  operation,  and 
there  has  been  a  partial  reaccumulation  of  blood. 

Hematoma  in  the  New  Born. — Blood  often  collects  between  the 
periosteum  and  the  skull  of  a  child  that  is  delivered  by  forceps. 
It  may  be  difficult  to  distinguish  between  a  hematoma  of  this  char- 
acter and  a  contusion  with  edema.  Two  or  three  days  later,  when 
the  edema  of  the  scalp  has  subsided,  but  a  fluctuating  swelling 
persists  beneath  it,  the  diagnosis  is  clear.  This  effused  blood 
should  be  evacuated  through  a  small  incision,  in  the  manner  de- 
scribed above,  because  its  resorption  is  very  slow  and  because  the 
periosteum  lifted  from  the  skull  continues  to  form  new  bone.  In 
this  manner  in  some  cases  a  prominent  and  permanent  thickening 
of  the  skull  develops.  Hence  the  desirability  of  removing  the  blood 
as  soon  as  possible,  and  of  keeping  the  loosened  periosteum  pressed 

against  the  skull  for  a  few 
days  until  it  reattaches  itself. 
Hematoma  of  Ear  (Boxer's 
Ear) .  —  Blows  upon  the  ear 
may  give  rise  to  hemorrhage 
beneath  the  perichondrium. 
The  effused  blood  causes  a 
rounded  fluctuating  tumor 
(Figs.  1  and  2)  which  may 
stretch  the  ear  far  beyond  its 
normal  size  and  completely 
change  its  appearance,  or  it 
may  be  confined  to  a  small 
portion  of  the  pinna  (Fig.  2). 
It  is  more  often  anterior  than 
posterior.  Absorption  of  the 
effused  blood  is  extremely 
slow,  and  the  tumor  should 
therefore  be  promptly  incised, 
the  blood  clots  thoroughly  re- 
moved, and  the  wound  su- 
tured. The  skin  of  the  ear  has  a  good  blood  supply,  and  wounds 
in  it  heal  promptly  if  the  edges  are  accurately  approximated  by 
sutures. 


Fig.  1. — Hematoma  of  Ear  from  a  Blow. 
The  perichondrium  is  lifted  over  a  con- 
siderable portion  of  the  pinna. 


HEMORRHAGE   FROM   THE    NOSE 


5 


Hemorrhage  from  the  Nose. — Hemorrhage  from  the  nose, 
or  epistaxis,  may  follow  a  blow  either  with  or  without  fracture  of 
the  nasal  bones,  or  it  may  result  from  picking  at  the  nose  or  the 
removal  of  dried  secretion.    It 
is  one  of  the  forms  of  vicari- 
ous menstruation.     It  is  also 
a  symptom  of  tuberculosis,  of 
syphilis    and    malignant    tu- 
mors, and  of  many  fevers.     It 
is  one  of  the  signs  of  fracture 
of  the  base  of  the  skull. 

The  blood  may  flow  in 
drops  or  in  a  steady  stream, 
or  occasionally  it  may  be  seen 
to  spurt  from  an  artery  of  the 
septum. 

Treatment. — In  the  ma- 
jority of  instances  the  hemor- 
rhage will  cease  spontaneously 
in  a  few  minutes.  The  pa- 
tient should  not  lean  forward 
nor  lie  upon  his  face.  The 
head  should  be  held  erect,  or 
it  should  be  bent  slightly  back- 
ward, so  that  the  blood  may 
accumulate  and  form  a  clot  in 
the  nostril.  If  the  blood  tric- 
kles into  the  naso-pharynx,  it  should  be  quietly  expectorated.  The 
patient  should  avoid  any  attempt  to  clear  the  nostrils  by  blowing. 
The  application  of  cold  in  the  shape  of  ice  or  some  metallic  object, 
like  a  large  door-key,  to  the  back  of  the  neck  is  a  well-tried  house- 
hold remedy  which  has  often  proved  effective.  The  holding  of  ice 
in  the  mouth  or  snuffing  ice-water  up  into  the  nostrils  may  also 
suffice  to  stop  the  bleeding.  Many  popular  remedies  have  doubt- 
less won  fame  because  of  the  tendency  of  the  hemorrhage  in  most 
cases  to  cease  in  a  few  minutes.  In  adults  of  a  plethoric  type  fre- 
quent nosebleed  seems  to  be  really  beneficial  by  reducing  the  ten- 
sion in  the  arteries.  There  are  cases,  however,  in  which  the  hemor- 
rhage is  alarming,   and  the  patient  may  even  be  in  danger  of 


Fig.  2. — Small,  Hematoma  of  Ear  Fol- 
lowing a  Blow  Three  Weeks  Pre- 
vious. Patient  a  man  aged  forty-one 
years. 


6  INJURIES  OF  THE   HEAD 

bleeding  to  death.     In  other  cases  the  bleeding  is  so  annoying  that 
it  becomes  desirable  to  cheek  it  at  once. 

To  check  the  hemorrhage  the  nostril  from  which  the  hemor- 
rhage comes  should  be  sponged  clean  and  a  systematic  search  made 
for  the  bleeding  point.  The  head  should  be  tipped  back  to  allow 
the  blood  to  How  out  of  the  posterior  mares.  In  this  manner  the 
anterior  nares  can  be  carefully  inspected.  The  bleeding  point  will 
often  be  found  low  down  upon  the  septum,  about  half  an  inch 
above  the  floor  of  the  nasal  passage  and  half  an  inch  or  more  from 
the  anterior  orifice.  Here  it  may  be  touched  with  a  chemical 
caustic  or  by  a  hot  probe,  the  shaft  of  which  has  been  wrapped 
in  order  to  avoid  burning  the  tip  of  the  nose,  or  by  the  finest  point 
of  a  thermo-cautery.  By  far  the  best  styptic  is  adrenalin  or  the 
extract  of  the  suprarenal  gland.  Cotton  moistened  with  this 
should  be  applied  to  the  bleeding  spot,  or  a  dilute  solution 
(1:10,000)  may  be  snuffed  up  the  nostril.  Peroxide  of  hydro- 
gen is  another  excellent  styptic. 

If  the  bleeding  cannot  be  stopped  in  one  of  the  ways  mentioned, 
it  may  be  necessary  to  plug  the  nasal  cavity  through  the  anterior 
nares.  A  narrow  strip  of  gauze  about  two  feet  long  is  soaked  with 
peroxide  of  hydrogen  and  squeezed  dry.  The  anterior  nares  is 
dilated  and  the  end  of  the  strip  passed  well  back  in  the  nose  with 
slender  forceps.  The  packing  is  continued  from  behind  forward 
until  the  cavity  has  been  filled.  Should  this  packing  fail  to  con- 
trol the  hemorrhage,  the  gauze  should  be  withdrawn  and  the  pos- 
terior nares  plugged.  This  disagreeable  procedure  is  best  accom- 
plished by  passing  through  the  anterior  nares  a  catheter  or  small 
rubber  tube,  through  the  eye  of  which  a  thread  has  been  drawn. 
As  the  catheter  appears  in  the  pharynx  the  thread  can  be  caught 
with  a  hook  and  one  end  of  it  drawn  out  of  the  mouth.  The 
catheter  is  then  withdrawn,  the  string  remaining  in  position 
through  the  nose  and  out  of  the  mouth.  A  specially  devised  in- 
strument for  this  purpose,  known  as  Bellocq's  canula,  has  a  curved 
spring  which  carries  the  thread  forward  beneath  the  soft  palate, 
thus  making  its  extraction  more  easy.  When  the  string  is  once 
in  position,  a  pledget  of  cotton  may  be  tied  to  the  end  which 
emerges  from  the  mouth,  and  passed  well  into  the  posterior  nares 
by  drawing  the  string  through  the  nose.  The  anterior  nares 
should  then  be  plugged  with  gauze  or  cotton.     Both  ends  of  the 


ABRASIONS 


string  should  be  secured  by  tying  them  together  or  fastening 
them  on  the  cheek  by  adhesive  plaster.  Otherwise  there  may 
be  difficulty  in  removing  the  posterior  plug.  This  procedure  is  at 
best  a  clumsy  method  of  stopping  hemorrhage,  and  should  not  be 
resorted  to  unless  other  measures  fail. 

When  once  a  clot  has  formed  and  hemorrhage  has  ceased,  both 
patient  and  physician  should  for  a  day  or  two  resist  the  tempta- 
tion to  remove  the  tampon  until  the  secretions  of  the  nose  lift  it 
from  the  surface  of  the  mucous  membrane,  so  that  it  can  be  ex- 
tracted easily  and  without  starting  fresh  hemorrhage.  After  that, 
gentle  irrigation  with  a  weak  alkaline  solution  should  be  employed 
to  cleanse  the  nostril. 

Abrasions. — Abrasions  of  the  scalp  and  face  are  of  impor- 
tance as  possible  sources  of  infection.  Abrasions  of  the  face  are 
important  also  because 
they  may  contain  par- 
ticles of  sand,  coal  dust, 
etc.,  which  healing  in 
the  wound  may  perma- 
nently disfigure  the  pa- 
tient. Hence  the  neces- 
sity that  all  abrasions 
of  the  head  should  be 
cleansed  thoroughly  and 
then  covered  with  gauze 
moistened  with  a  weak 
antiseptic,  such  as  alu- 
minum acetate  (four 
per  cent  solution)  or 
creolin  (1:200)  held 
in  place  by  a  gauze 
bandage.  The  dressing 
should  be  moistened 
with  cold  water  every 
two  hours.  If  kept 
moist  in  this  way  the 
dressing  can  be  changed  every  day  without  irritating  the  wound. 
It  is  more  easy  to  keep  a  wound  of  the  scalp  clean  if  a  border  an 
inch  wide  has  been  shaved  around  it.    In  a  day  or  two  the  risk  of 


Fig.  3. 


-Powder    Grains   in  Face    from  a   Re- 
cent Explosion. 


8 


INJURIES   OF  THE   HEAD 


infection  will  have  passed,  and  the  abrasions  may  be  allowed  to 
dry,  or  they  may  be  covered  by  boracic  acid  ointment  until  new 
epithelium  lias  formed. 

Removal  of  Powder  Grains. —  In  abrasions  of  the  face  the  sur- 
geon's attention  should  be  directed  to  the  removal  of  every  particle 

of  dirt,  as  insoluble  sub- 
stances, such  as  grains 
of  sand,  may  be  covered 
over  by  epithelium  and 
form  permanent  colored 
marks  in  the  skin,  like 
tattooing.  This  is  es- 
pecially the  case  with 
powder  grains.  These 
are  so  small  and  soft 
and  numerous  that  it  is 
hopeless  to  attempt  to 
pick  them  out  one  by 
one.  It  is  most  impor- 
tant, however,  that  they 
be  removed.  It  is  best 
to  give  the  patient  an 
anesthetic  and  then  to 
scrub  the  wounded  area 
with  a  stiff  brush  until 
every  trace  of  powder 
has  been  scraped  away 
(Figs.  3  and  4),  for 
once  the  skin  has  healed 
over  them  it  is  impos- 
sible to  get  them  all  out  by  cutting  or  caustics  without  leaving 
marked  scars. 

Foreign  Bodies. — Foreign  bodies  frequently  lodge  in  the  eye, 
ear,  nose,  or  mouth,  and  the  rules  for  their  extraction  vary  in  these 
different  situations.  Foreign  bodies  in  wounds  are  described  on 
page  14. 

Foreign  Bodies  in  the  Eye. — A  patient  will  usually  make  the 
diagnosis  of  a  foreign  body  in  the  eye  by  a  feeling  of  pain  or  dis- 
comfort.   Frequently  he  can  locate  a  small  foreign  body  with  great 


Fig.  4. — Powder  Grains  Removed  by  Scrubbing 
with  a  Stiff  Brush  while  the  Patient  is 
Fully  Etherized.  All  the  grains  were  re- 
moved in  this  manner.  The  dark  spots  in  the 
photograph  are  the  slight  resultant  wounds. 
There  was  no  permanent  scar. 


FOREIGN   BODIES  9 

exactness,  although  usually  unable  to  say  whether  it  is  in  the 
eyelid  or  eyeball. 

The  eye  should  be  examined  in  a  good  light,  first  by  direct 
light,  and  then  if  the  foreign  body  is  not  discovered,  by  side  light. 
The  lower  lid  should  be  depressed  to  permit  examination  of  the 
lower  half  of  the  eye.  The  patient  should  then  be  directed  to  look 
downward.  The  eyelashes  of  the  upper  lid  are  seized,  and  the  lid 
is  everted  by  lifting  its  lower  edge  outward  and  upward  at  the  same 
time  that  the  upper  margin  of  the  tarsal  cartilage  is  depressed  with 
the  tip  of  a  finger,  or  with  the  end  of  a  glass  rod  or  pencil. 

When  the  foreign  body  is  discovered,  it  may  be  wiped  away 
with  a  bit  of  absorbent  cotton  wrung  out  of  saline  solution,  or 
out  of  a  solution  of  boracic  acid ;  or  it  may  be  removed  with  a  blunt 
instrument,  such  as  a  spud  or  a  match  whittled  to  a  not  too  fine 
point. 

If  the  cinder  or  minute  particle  of  steel  or  glass  is  embedded 
in  the  cornea,  it  is  well  to  drop  a  little  weak  cocain  solution  (one 
or  two  per  cent)  into  the  eye  to  assist  the  patient  in  keeping  the 
eyeball  quiet  while  the  operator  works  out  every  particle  of  the 
foreign  body. 

Most  writers  upon  diseases  of  the  eye  advocate  the  use  of  fairly 
strong  antiseptics  for  the  purpose  of  disinfecting  the  wound  in 
which  the  foreign  body  lay.  This  method  of  treatment  was  for- 
merly advocated  in  the  case  of  larger  wounds  of  the  body,  but  it  is 
now  pretty  generally  understood  by  surgeons  that  such  solutions 
have  little  effect  other  than  that  of  the  fluid  itself.  The  rational 
procedure,  therefore,  is  to  bathe  the  eye  with  a  weak  antiseptic, 
such  as  a  half  saturated  solution  of  boracic  acid,  or  a  normal 
saline  solution  every  two  or  three  hours,  and  to  trust  to  the 
antiseptic  action  of  the  tears  and  of  the  internal  fluids  of  the 
body  to  protect  the  eye  from  infection.  Pain  is  much  relieved 
by  the  application  of  ice  cloths,  and  protection  of  the  eye  from 
strong  light. 

If  the  foreign  body  has  penetrated  more  deeply  into  the  eye 
than  the  cornea,  the  aim  of  treatment  is  to  remove  it  with  as  little 
damage  to  the  eyeball  as  possible.  A  patient  with  such  a  serious 
lesion  should  be  treated  from  the  first  by  a  specialist  when  circum- 
stances permit.  Some  writers  upon  the  eye  praise  the  use  of  a 
magnet  for  the  removal  of  bits  of  steel  and  iron,  while  others  say 


10  INJURIES  OF  THE  HEAD 

that  it  is  of  no  use,  even  when  such  a  foreign  body  is  situated 
superficially. 

Foreign  Bodies  in  the  Ear  and  Nose. — Beans,  shoe  buttons,  and 
other  objects  arc  poked  into  the  ear  or  nose  by  children.  If  they 
arc  smooth  they  may  set  up  no  irritation,  but  generally  there  is 
enough  swelling  of  the  mucous  membrane  to  reduce  the  size  of  the 
opening  and  make  their  extraction  difficult.  If  a  foreign  body  is 
sharp,  so  that  the  mucous  membrane  is  broken,  either  at  the  time 
or  later,  there  will  be  a  continuous  discharge  from  the  affected 
nostril,  or  from  the  ear,  as  the  case  may  be.  A  persistent  uni- 
lateral nasal  discharge  in  the  case  of  a  child  always  suggests  a 
foreign  body. 

The  amount  of  pain  varies  in  different  cases,  according  to  the 
situation,  size,  and  shape  of  the  article,  and  the  amount  of  injury 
done  at  the  time  of  its  entrance. 

The  diagnosis  may  be  suspected  from  the  history  or  symptoms, 
but  it  rests  chiefly  upon  the  results  of  direct  inspection  through  a 
suitable  speculum.  If  the  patient  is  a  young  child,  complete  anes- 
thesia is  desirable  for  this  examination  as  well  as  for  subsequent 
treatment. 

Teeatment. — It  is  absolutely  necessary  that  the  patient's  head 
should  be  still  during  attempts  at  extraction  even  if  general  anes- 
thesia has  to  be  employed  to  accomplish  this  object.  If  the  foreign 
body  is  one  which  may  be  firmly  grasped  with  mouse-tooth  for- 
ceps, it  can  be  slowly  and  steadily  extracted.  The  necessary  in- 
struments are  shown  in  Figure  5.  If  the  foreign  body  is  smooth 
and  hard  as,  for  instance,  a  round  glass  bead,  a  bit  of  shoe- 
maker's wax  may  be  utilized  to  obtain  a  hold  upon  it,  or  a  probe 
or  blunt  hook  of  bent  wire  may  be  passed  alongside  of  it.  Light 
substances,  such  as  insects,  may  possibly  be  floated  out  of  the 
ear  on  the  surface  of  olive  oil  poured  into  the  meatus.  This 
is  also  a  good  way  to  drown  an  insect,  and  stop  its  motions  in 
the  ear. 

One  of  the  commonest  foreign  bodies  the  surgeon  is  called  upon 
to  extract  from  the  ear  is  a  mass  of  ear-wax.  Normally  the  wax 
which  is  secreted  in  the  ear  works  outward  as  a  thin,  hollow  cylin- 
der, the  outer  edges  of  which  dry  up  and  break  off  in  scales.  If 
an  overzealous  individual  attempts  to  free  his  ear  of  wax  by  means 
of  a  slender  cone,  for  example,  the  twisted  corner  of  a  wet  towel, 


FOREIGN    BODIES  11 

it  sometimes  happens  that  the  edges  of  the  thin  cylinder  of  wax 
are  pushed  inward  from  time  to  time  until  a  large  ball  of  wax  is 
formed.  This  is  not  usually  noticed  until  some  jar  dislodges  it 
and  it  falls  against  the  drum-membrane,  causing  a  constant  buzz- 


Fig.  5. — Instruments  for  the  Extraction  of  Foreign  Bodies  from  the  Nose 
and  Ear:  A,  Cotton  carriers  made  of  flattened  copper  wire;  B,  Pure  silver  slender 
■    probe;  C,  Ear  specula;  D,  Nasal  speculum;    E,   Forceps   bent    at  a    convenient 
angle;  F,  Curette. 

ing  sound  and  a  general  feeling  of  uneasiness  inside  the  head.  As 
this  continues  and  hearing  is  possibly  interfered  with,  the  indi- 
vidual seeks  medical  aid,  under  the  supposition  that  he  has  some 


12  INJURIES   OF  THE   HEAD 

serious  ear  trouble.  From  the  symptoms  alone  the  diagnosis  can 
usually  be  made. 

An  examination  through  an  ear  speculum  reveals  the  hall  of 
wax  at  a  greater  or  less  depth  from  the  surface.  Through  as 
large  a  -speculum  as  the  ear  will  conveniently  receive,  slender  for- 
ceps bent  at  a  suitable  angle  may  be  passed  into  the  ear  until 
they  touch  the  wax  (Fig.  5).  The  ball  may  be  seized  and  a 
number  of  fragments  drawn  outward  through  the  speculum.  The 
success  of  this  method  depends  as  much  upon  the  consistency  <>t' 
the  wax  as  upon  the  dexterity  of  the  surgeon.  If  the  wax  is  firm 
it  can  all  be  removed  in  a  few  minutes.  If  it  is  soft  very  little 
of  it  can  be  extracted  in  this  manner,  and  removal  by  syringing 
has  to  be  resorted  to.  .V  fountain  syringe  or  irrigator  is  filled  with 
a  warm  dilute  solution  of  bicarbonate  of  soda  (a  teaspoonful  to  the 
pint)  and  placed  high  enough  to  give  slight  force  to  the  escaping 
stream,  which  is  then  directed,  either  with  or  without  the  specu- 
lum, full  against  the  plug  of  wax,  the  ear  being  lifted  upward  and 
backward  to  dilate  and  straighten  the  canal.  The  wax  is  made  less 
viscid  by  the  fluid,  and  is  separated  from  the  walls  of  the  meatus 
to  a  certain  extent,  and  in  most  cases  half  an  hour's  syringing, 
interrupted  by  occasional  extraction  of  fragments  with  the  forceps, 
or  with  the  curette,  will  suffice  to  empty  the  meatus.  If  not,  the 
procedure  can  be  resumed  the  following  day.  When  the  wax  or 
other  foreign  body  has  been  removed,  the  ear  should  be  carefully 
examined  for  the  presence  of  inflammation.  If  the  surface  is 
merely  excoriated,  an  occasional  antiseptic  irrigation  or  dusting 
with  powdered  boracic  acid  is  sufficient  treatment. 

Foreign  Bodies  in  the  Mouth  and  Throat. — Small  foreign  bodies 
may  become  lodged  in  some  crevice  of  the  mouth  or  throat,  or  if 
sharp,  they  may  penetrate  the  mucous  membrane,  and  thus  resist 
the  patient's  efforts  to  eject  or  swallow  them.  A  fish  bone,  a 
splinter,  or  a  fragment  of  straw  is  the  object  that  usually  be- 
comes embedded. 

The  sensations  of  the  patient  are  in  most  cases  a  reliable  guide 
to  the  location  of  the  foreign  body.  It  is  possible  for  a  rough 
object  to  scratch  the  throat  during  the  act  of  swallowing,  and  leave 
behind  it  the  sensation  of  a  foreign  body.  It  is  the  exception, 
however,  for  the  patient  to  be  mistaken  in  this  way,  so  that  the 
physician  ought  in  every  case  to  make  an  examination  with  a 


WOUNDS  13 

strong  reflected  or  direct  light  and  a  throat  mirror.  The  latter  is 
of  the  greatest  service  in  hunting  for  small,  colorless  objects,  since 
it  enables  the  examiner  to  inspect  the  tonsil  and  the  pillars  of  the 
fauces  from  diiferent  angles.  These  are  the  situations  in  which 
most  small  foreign  bodies  become  lodged.  When  found,  the  foreign 
body  can  be  extracted  with  the  forceps,  or  worked  loose  with  a  probe 
or  bent  wire.  If  the  search  is  fruitless,  it  should  be  resumed  on 
the  following  day,  provided  the  symptoms  in  the  meantime  have 
not  subsided. 

Foreign  bodies  in  the  larynx  and  esophagus  are  described  on 
page  115. 

Wounds. — The  diiferent  varieties  of  wounds — incised,  lacer- 
ated, et  cetera — are  found  with  frequency  upon  all  portions  of  the 
head.  The  blood  supply  of  the  scalp  and  of  the  skin  of  the  face 
is  so  free  that  no  matter  how  jagged  a  wound  may  be,  the  vitality 
of  its  points  is  usually  preserved. 

Owing  to  the  smooth,  hard  surface  of  the  skull,  a  blow  upon 
the  scalp  with  a  blunt  instrument,  such  as  a  policeman's  club,  will 
produce  a  fairly  clean  cut  wound,  almost  like  that  made  with  a 
knife.  A  careful  inspection  of  its  edges,  however,  will  show  a  con- 
tused area  more  or  less  circular,  and  about  an  inch  in  diameter, 
which  represents  the  area  of  contact  of  the  instrument  with  which 
the  blow  was  given. 

Treatment. — The  first  object  of  treatment  is  to  control  hem- 
orrhage, either  by  pressure  or  ligation  of  the  bleeding  vessels; 
the  second  is  to  determine  the  extent  of  the  wound,  the  third 
to  remove  any  foreign  bodies  which  may  be  present,  and  the  fourth 
to  approximate,  by  suture  or  otherwise,  the  tissues  which  have  been 
divided,  whether  skin  or  deeper  structures. 

It  should  be  an  invariable  rule  never  to  pass  a  probe  into  a 
wound,  especially  a  wound  of  the  scalp,  until  the  skin  has  been 
cleaned  as  for  operation ;  otherwise  the  probe  may  spread  infec- 
tion to  the  deeper  portions  of  the  wound,  which  in  the  particular 
case  mentioned  may  be  the  surface  of  the  brain. 

The  skin  should  be  thoroughly  washed  with  soap  and  water, 
then  with  some  solvent  of  grease,  such  as  ether,  or  turpentine  fol- 
lowed by  alcohol,  and  dried  by  gauze  sponges  or  cotton  swabs 
wrung  out  of  an  antiseptic  solution  (p.  34).  The  wound  should 
be  cleansed  with  saline  solution,  or  stronger  solutions,  according 


14  INJURIES  OF  THE   HEAD 

id  circumstances,  lis  edges  should  be  retracted,  and  the  possi- 
bility of  dot'])  injury  determined.  Small  foreign  bodies  should  be 
removed. 

If  a  foreign  body  such  as  a  splinter  passes  nnder  the  skin,  the 
sinus  made  by  it  should  be  split  up  and  thoroughly  cleansed,  for 
if  allowed  to  remain  undisturbed  it  is  almost  certain  to  cause  sup- 
puration and  delay  recovery.  A  bullet  of  small  caliber  may  pene- 
trate the  seal])  al  one  point,  pass  along  outside  of  the  skull,  and 
emerge  at  another,  or  remain  between  the  periosteum  and  the  skin. 
In  such  a  ease  the  bullet  should  be  removed  by  an  incision  over  it, 
the  sinus  irrigated  with  peroxid  of  hydrogen  solution,  1:8  or 
weaker,  and  1  :  2,000  biehlorid  solution,  and  pressure  applied 
throughout  its  length  except  at  its  ends,  which  should  be  kept  open 
by  small  strips  of  gutta-percha  tissue  or  gauze.  In  this  manner 
union  can  ordinarily-  be  secured  without  dividing  the  intervening 

Most  small  wounds  of  the  face  and  scalp  should  be  sutured 
without  drainage,  or  at  most,  a  flat  gutta-percha  or  horsehair 
drain  should  be  employed  (Fig.  306).  Carefully  applied  pressure 
obtained  by  bandaging  a  dry  compress  of  gauze  to  the  head  will 
prevent  reaccumulation  of  blood  in  the  wound. 

While  it  is  generally  true  that  all  the  ragged  points  of  a  wound 
of  the  face  or  scalp  will  live,  it  is  better  for  the  sake  of  a  clean 
scar  to  trim  the  edges  of  the  wound  so  that  they  may  be  smoothly 
approximated.  Especial  attention  should  be  given  to  the  direction 
of  hairs  whose  roots  are  often  twisted  and  displaced  by  rough 
injuries.  Horsehair  or  fine  black  silk  is  the  best  material  for  the 
suture. 

Some  surgeons  have  advocated  a  subcuticular  suture.  This  is 
introduced  with  a  curved  needle  which  passes  into  and  out  of  the 
skin,  first  on  one  side  of  the  wound  and  then  on  the  other,  without 
reaching  the  surface.  This  suture  is  more  difficult  of  application 
than  other  sutures,  and  it  sometimes  fails  to  approximate  accu- 
rately the  overlying  epidermis.  If  the  thread  used  for  an  inter- 
rupted suture  is  a  very  fine  black  sewing-silk  (JSTo.  A),  and  the 
^  sutures  are  taken  out  in  from  two  to  four  days,  no  permanent  scars 
due  to  the  punctures  will  remain. 

Wounds  of  the  Eye. — If  a  laceration  extends  through  both  the 
skin  and  conjunctiva  of  the  eyelid,  some  of  the  sutures  should  pass 


WOUNDS  15 

through  both  structures,  so  as  to  approximate  the  edges  of  the 
conjunctiva.     Other  sutures  should  be  placed  in  the  skin  only. 
All  of  them  should  be  removable  from  the  outside.     In  treating 
wounds  of  the  eyeball,  repair  with  the  least  disturbance  of  the  nor- 
mal relations  should  be  the  aim  of  the  operator.     Protruding  por- 
tions of  the  iris  should  be  snipped  off.     Wounds  of  the  sclerotic 
coat,  if  sufficiently  large,  should  be  sutured  with  the  finest  catgut. 
The  eye  should  be  washed  with  Thiersch's  solution  (salicylic  acid 
2,  boric  acid  12,  boiled  water  1,000  parts)  one-half  strength,  or  u, 
half-saturated  solution  of  boracic  acid,  or  a  normal  salt  solution.!. 
A  light  pad  of  gauze  moistened  with  one  of  these  solutions  should 
be  applied.     The  bandage  (Fig.  326)  should  be  light  so  that  evap-j 
oration  may  keep  the  eye  cool.   ISTo  rubber  protective  is  permissible.; 
The  moisture  should  be  kept  up  by  adding  from  time  to  time  more 
of  the  solution  or  cold  boiled  water.     If  the  injury  is  serious  the 
patient  should  remain  in  bed  until  repair  is  well  established.     The 
services  of  an  ophthalmic  surgeon  should  be  obtained  in  these  cases 
whenever  possible. 

Wounds  of  the  Mouth. — Wounds  within  the  mouth  are  con- 
stantly filled  with  bacteria,  some  of  them  pathogenic.  Neverthe- 
less, they  usually  heal  with  little  delay,  owing  to  constant  mois- 
ture and  the  extremely  free  blood  supply.  It  is  rare  that  the 
surgeon  is  called  upon  to  treat  a  bitten  tongue  or  cheek.  If,  how- 
ever, so  large  a  flap  has  been  separated  from  the  main  tissue  that 
untreated  it  would  cause  a  permanent  roughness  in  the  mouth,  one 
or  more  sutures  of  fine  black  silk  should  be  inserted  with  a  curved 
needle.  Plain  catgut  soon  swells  and  softens  and  loses  its  grip. 
Catgut  prepared  so  as  to  resist  moisture  (e.  g.,  chromicized)  is  stiff 
and  unpleasant;  fine  silk,  dyed  black  so  as  to  be  readily  seen,  is 
therefore  the  best  suture  material  for  the  mouth. 

If  the  lip  or  cheek  is  cut  through,  cutaneous  sutures  passed 
through  all  the  tissues  except  the  mucous  membrane  will  suf- 
ficiently hold  the  parts  in  place,  or  the  mucous  membrane  may  first 
be  sutured  with  catgut  or  silk,  the  knots  being  tied  inside  the 
mouth.  If  silk  is  used  the  sutures  should  be  so  placed  that  their 
extraction  will  be  easy.  The  mouth  should  be  kept  clean  by  rins- 
ing with  a  mild  antiseptic  solution,  and,  if  necessary,  remnants  of 
food  should  be  wiped  with  wet  cotton  swabs  from  the  vicinity  of 
the  wound. 


16 


INJURIES   OF  THE   HEAD 


Steno's  duct,  or  the  facial  nerve,  may  be  divided  in  wounds 
of  the  check  (Fig.  6).  Immediate  suture  should  be  performed, 
or  even  late  suture  if  the  accident  is  overlooked  at  first.     If  the 

two  divided  portions  of 
Steno's  duct  have  become 
separated  by  scar  tissue, 
the  anterior  portion  of 
the  duct  can  usually  be 
]>  robed,  and  the  probe 
thrust  into  the  posterior, 
then  dilated  portion. 
The  channel  may  be  re- 
stored by  tying  the  probe 
in  place  for  a  day  or 
so,  or  a  ligature  may  be 
passed  through  the  duct 
beyond  the  scar  and  into 
the  mouth.  As  soon  as 
the  normal  channel  is  re- 
established, such  an  arti- 
ficial fistula  will  close  as 
soon  as  the  thread  is  re- 
moved. A  small  exter- 
nal fistula  due  to  an  in- 
cision into  the  substance 
of  the  gland,  will  usu- 
ally close  of  itself  in  a 
few  days. 

The  paralysis  of  the  mouth,  and  possibly  also  of  the  eyelids  due 
to  division  of  the  facial  nerve,  can  hardly  be  overlooked.  The 
nerve  should  be  sutured  at  once ;  see  Chapter  XIII  for  the  technic. 
Wounds  of  the  Periosteum. — In  incised  and  punctured  wounds 
of  the  scalp,  the  periosteum  is  often  injured.  This  serious  com- 
plication can  be  recognized  by  retraction  of  the  edges  of  the  wound 
and  inspection  and  probing  of  its  deeper  portion.  If  merely  the 
overlying  aponeurosis  is  divided,  one  may  be  misled  into  supposing 
that  it  is  the  periosteum.  If  the  latter  is  also  divided  the  probe 
will  clearly  detect  the  underlying  bone.  Such  a  wound  should  be 
thoroughly  examined,  cleansed,  and  drained.     It  is  better  to  delay 


Fig.  6. — Division  of  Steno's  Duct  by  a  Razor. 
The  skin  was  sutured  and  the  division  of  the 
duct  was  not  noticed  until  the  obstructing 
scar  caused  distention  behind  it.  This  patient 
was  promptly  cured  by  the  method  described 
above. 


FRACTURES  17 

union  for  a  few  days  by  the  presence  of  a  gauze  drain  than  to 
suture  the  periosteum  and  run  the  risk  of  abscess  formation  be- 
neath it.  The  mere  exposure  of  the  skull  for  a  few  days  will  not 
result  in  necrosis  if  suppuration  does  not  coexist;  whereas  an  in- 
fected punctured  wound,  for  example  over  the  eye,  may  be  fol- 
lowed by  suppuration  under  the  periosteum  which,  if  neglected, 
may  pass  through  the  skull  and  set  up  a  fatal  suppurative  menin- 
gitis. Therefore  the  fresh  wound  should  be  only  partially  sutured, 
while  a  strip  of  gauze  should  reach  to  the  periosteum  in  the  center 
of  the  wound.  This  drain  may  be  withdrawn  in  forty-eight  hours, 
and  if  the  wound  is  still  clean  it  may  be  allowed  to  close;  if  it  is 
suppurating  it  should  be  washed  out  with  mild  antiseptics  and 
drained  again,  and  a  wet  dressing  applied. 

Fractures.— Fracture  cf  the  Skull. —  In  many  instances  it  is 
impossible  to  diagnose  a  simple  fracture  of  the  skull  except  by  ac- 
companying signs.  These  are  local  pain  and  tenderness,  hemor- 
rhage— the  blood  appearing  in  the  orbit  or  coming  from  the  ear — 
headache,  shock,  partial  paralysis,  pupils  irregularly  contracted  or 
dilated,  and  partial  or  complete  unconsciousness.  Shock,  even  to 
complete  unconsciousness,  may  be  present  from  concussion  of  the 
brain  (really  contusion  of  the  brain)  without  fracture  of  the  skull ; 
and  fracture  of  the  skull,  especially  if  it  is  caused  by  a  fairly  sharp 
instrument  and  if  it  involves  bone  which  overlies  the  less  impor- 
tant portions  of  the  brain,  may  be  unaccompanied  by  shock.  This 
is  especially  true  of  the  occipital  region.  Hemorrhage  in  the  orbit, 
appearing  usually  under  the  conjunctiva,  or  from  the  nose  (if  frac- 
ture of  the  nose  is  absent),  or  from  the  ear,  or  appearing  under  the 
skin  in  these  localities,  is  considered  to  be  pathognomonic  of  frac- 
ture of  the  base  of  the  skull.  Under  such  circumstances  operative 
treatment  is  out  of  the  question.  Absolute  quiet  in  a  cool,  dark 
room,  with  external  heat  to  the  extremities,  and  cardiac  stimulants, 
if  necessary,  are  the  best  means  to  be  employed.  If  external 
wounds  are  present  the  most  rigid  asepsis  should  be  observed  in 
their  treatment.  If  the  lesion  in  the  skull  is  extensive  or  a  por- 
tion of  the  bone  is  depressed,  it  is  better  not  to  attempt  repair  at 
the  time  of  the  accident,  but  simply  to  protect  the  wound  by  a  moist 
antiseptic,  or  dry  sterile  dressing,  until  arrangements  for  a  for- 
midable operation  can  be  completed. 

Fluctuating  hematoma  of  the  scalp,  surrounded  by  a  ring  of 


IS 


INJURIES   OF  THE    HEAD 


resistant  edema,  may  give  the  impression  thai  the  bone  in  its  center 
is  depressed.  This  error  is  to  he  avoided  by  noting  the  natural 
curve  of  the  skull  outside  of  the  edematous  area. 

Fracture  into  a  Frontal  Sinus. — A  fracture  of  the  frontal  bone 
just  about  the  orbit  may  involve  only  the  outer  wall  of  the  frontal 
sinus.     This  is  not  usually  a  serious  lesion,  but  the  bone  should  be 

replaced  in  its  normal 
position  so  that  per- 
manent disfigurement 
may  be  avoided. 

To  accomplish  this 
it  may  be  necessary  to 
make  an  incision  be- 
neath (lie  eyebrow. 

Fracture  of  the  Ma- 
lar Bone. — This  injury 
is  due  to  direct  vio- 
lence, and  the  bone  is 
almost  invariably  dis- 
placed b  a  c  k  w  a  r  d  so 
that  one  cheek  is  less 
prominent  than  the 
other  (Fig.  T). 

To  replace  it  in  po- 
sition, anesthetize  the 
patient,  chisel  a  hole 
into  the  antrum  just 
above  the  first  bicuspid 
tooth  and  introduce  a  curved  steel  sound.  With  this  instrument 
as  a  lever,  firm,  steady  pressure  may  be  exerted  upon  the  inner 
surface  of  the  malar  until  it  is  brought  into  its  normal  position. 
A  mouth  wash  is  the  only  after  treatment  required. 

Fracture  of  the  Nasal  Bones. — The  nose  is  frequently  injured 
by  blows  and  falls,  so  that  the  nasal  bones  may  be  fractured,  or  the 
cartilages  torn  loose  from  them.  An  injury  of  this  sort  is  usually 
followed  by  more  or  less  hemorrhage  from  the  nares.  There  is 
also  subcutaneous  hemorrhage  and  edema,  so  that  it  is  difficult  to 
determine  from  external  examination  alone  whether  the  rigid  struc- 
tures have  been  altered.     Gentle  manipulation  of  the  bridge  of  the 


Fig.  7. 


-Fracture  of  Right  Malar  Bone  with 
Depression  from  Blow. 


FRACTURES  19 

nose  will  usually  elicit  crepitus  if  there  is  a  fracture.  This  should 
be  combined  with  inspection  of  the  nares  through  a  bivalve  specu- 
lum. Deformity  may  of  course  have  existed  previous  to  the  injury, 
and  the  patient  should  be  questioned  upon  this  point. 

■  The  hemorrhage  stops  in  a  few  minutes,  and  the  pain  is  slight ; 
but  the  patient  may  be  distressed  by  his  appearance,  or  by  the  fact 
that  the  swelling  and  hemorrhage  prevent  him  from  breathing 
through  his  nose;  but  both  nares  are  not  usually  obstructed. 

Treatment. — The  chief  object  of  treatment  is  the  reduction 
of  deformity,  and  the  maintenance  of  correct  relations  for  a  few 
days.  Whenever  possible,  existing  deformity  should  be  so  cor- 
rected or  overcorrected  that  there  is  no  further  tendency. for  the 
bones  to  slip  out  of  place.  A  blunt  steel  sound,  or  some  similar 
instrument  passed  into  the  nostril,  is  of  assistance  in.  correcting 
displacement. 

If  deformity  tends  to  recur,  it  may  be  necessary  to  insert  a  hol- 
low, perforated  rubber  cone  into  one  nostril,  or  to  apply  an  external 
splint.  This  can  be  made  of  dental  composition,  softened  in  hot 
water,  and  molded  to  the  nose,  or  a  pad  of  gutta-percha  tissue 
may  be  similarly  employed.  As  the  swelling  diminishes,  the  splint 
must  be  remolded.  The  surgeon  can  then  better  judge  whether 
all  deformity  has  been  corrected,  and  if  not  this  should  be  accom- 
plished before  union  becomes  solid.  If  the  patient  is  seen  several 
times  with  this  object  in  view,  it, will  rarely  be  necessary  to  make 
use  of  a  complicated  nasal  splint,  or  to  scar  the  face  by  passing  a 
hat  pin  directly  through  the  nose. 

Fracture  of  the  Superior  Maxilla. — This  is  one  of  the  less  com- 
mon fractures.  Deformity  is  easily  overcome,  and  after  reduc- 
tion the  fragments  will  usually  remain  in  a  correct  position,  since 
there  are  no  strong  muscles  tending  to  displace  them.  As  an  addi- 
tional safeguard,  wires  and  threads  may  be  used  to  bind  together 
teeth  attached  to  the  fragment,  and  those  of  the  remaining  part  of 
the  superior  maxilla,  as  described  below  in  connection  with  frac- 
ture of  the  inferior  maxilla. 

Fracture  of  the  Inferior  Maxilla  or  Mandible. — This  injury  is 
very  common,  and  often  seriously  affects  the  patient's  health. 
Moreover,  the  difficulty  of  keeping  the  fragments  in  correct  posi- 
tion often  taxes  the  ingenuity  of  the  surgeon  to  the  utmost.  The 
fracture  is  due  to  direct  violence,  and  almost  always  to  blows  re- 


20  INJURIES   OF  THE   HEAD 

ceived  in  a  fight.  The  line  of  fracture  usually  passes  through  the 
body  of  the  jaw,  back  of  the  canine  or  the  bicuspid  tooth.  It  may, 
however,  occur  at  other  places,  and  often  there  is  a  second  fracture, 
cither  on  the  other  side,  or  possibly  on  the  same  side,  in  which  case 
it  may  be  above  the  angle  of  the  jaw.  If  the  fracture  is  situated 
in  that  portion  of  the  jaw  occupied  by  the  teeth,  it  is  almost  ahvays 
compound  into  the  mouth. 

Diagnosis  is  made  from  inspection  and  manipulation,  as  well  as 
from  the  subjective  symptoms  of  pain  and  disability.  There  is 
local  swelling  and  tenderness.  Inspection  of  the  gums  will  usually 
show  a  break  in  the  continuity  of  the  mucous  membrane  at  the 
roots  of  the  teeth.  The  patient  cannot  open  his  mouth  fully,  nor 
can  he  bite  on  a  hard  substance,  for  example  a  cork.  Attempts  to 
open  and  close  the  mouth  may  produce  motion  at  the  site  of  frac- 
ture, shown  by  changes  in  the  relation  of  the  teeth  on  either  side 
of  the  break.  Such  displacements  can  be  readily  produced  by  the 
examiner,  if,  grasping  the  jaw  between  his  thumb  placed  under 
the  patient's  chin  and  two  fingers  placed  on  the  incisor  teeth,  he 
rocks  it  from  side  to  side. 

The  disability  due  to  this  fracture  is  great.  The  patient  is 
absolutely  unable  to  chew  solid  food,  even  if  it  were  desirable  to  let 
him  do  so,  or  to  open  the  jaw  except  to  a  slight  extent.  Pain  pre- 
vents him  from  sleeping,  and  abnormal  fermentations  within  the 
mouth  increase  the  swelling  and,  inflammation,  and  add  to  his  dis- 
gust and  discomfort. 

Treatment. — The  first  step  in  treatment  is  the  perfect  reduc- 
tion of  the  fragments,  under  a  general  anesthetic  if  necessary.  In 
some  cases  this  is  a  very  simple  procedure,  and  the  ends  of  the 
bone  when  reduced  show  no  tendency  to  become  displaced.  In 
other  cases  reduction  is  easy,  but  the  moment  that  the  surgeon  lets 
go  of  the  jaw  displacement  recurs.  In  a  third  class  of  cases  per- 
fect reduction  is  impossible,  or  can  only  be  accomplished  by  the 
exercise  of  considerable  force.  This  means  that  a  tooth  has  become 
loosened  and  wedged  between  the  fragments,  or  that  there  is  a  dis- 
placed small  fragment  of  bone  which  has  intervened  in  a  similar 
manner  to  prevent  the  reduction.  Such  offending  tooth,  or  frag- 
ment, should  of  course  be  removed. 

The  simplest  method  of  keeping  the  fractured  ends  of  the  bone 
in  apposition  is  to  bandage  the  jaws  firmly  together,  thus  making 


FRACTURES 


21 


the  upper  jaw  act  as  a  splint  for  the  lower  one.  A  four-tailed 
bandage  with  a  slit  or  narrow  ellipse  cut  in  its  center  through 
which  the  point  of  the  chin  protrudes  sufficiently  to  keep  the  hand- 
age  from  slipping,  is  tied  across  the  occiput  and  over  the  forehead, 
one  end  being  left  long  in  each  situation  (Fig. 
8  ) .  These  two  ends  are  then  tied  together  over 
the  top  of  the  head.  The  bandage  after  this 
application  is  shown  in  Figure  328,  Chapter 
XXI.  In  this  manner  any  desired  amount  of 
pressure  can  be  produced  upon  the  jaw, the  pull 
being  both  backward  and  upward.  This  meth- 
od of  treatment  makes  it  difficult  for  a  patient 
to  keep  his  mouth  in  proper  condition,  and  in- 
terferes with  feeding,  as  he  has  to  take  fluid 
nourishment  through  a  tube.  Pressure  of  the 
bandage  over  the  seat  of  fracture  often  adds  to 
the  patient's  discomfort;  but  it  is  by  far  the 
commonest  method  employed  on  account  of  its 
ready  application.  There  are  cases  in  which  it 
answers  the  purpose  admirably,  and  the  patient 
is  even  able  to  open  his  teeth  sufficiently  to 
brush  them  without  disturbing  the  fractured 
ends.  In  other  cases  the  bandage  is  a  miser- 
able failure.  Xon-success  is  usually  due  to 
the  fact  that  reduction  has  been  imperfectly 
accomplished,  or  to  the  fact  that  the  patient 
has  not  two  full  sets  of  teeth.  If  a  person  has 
all  of  his  natural  teeth,  pressure  of  one  set 
against  the  other,  and  the  repeated  slight  blows 
given  by  the  act  of  chewing  will,  during  the 
later  weeks  of  convalescence^  correct  any  slight 
irregularity  of  the  lower  jaw  which  still  exists, 
provided  that  reduction  does  not  require  much  force,  and  that  there 
are  at  least  two  teeth  back  of  the  line  of  fracture. 

If  this  simple  treatment  does  not  succeed,  or  if  for  other  rea- 
sons a  more  exact  method  of  treatment  is  indicated,  the  teeth  may 
be  wired  together.  For  this  purpose  two  flat  wires  should  be 
passed  along  the  lower  teeth,  one  inside  of  them  and  one  outside 
of  them,  and  they  should  be  lashed  to  the  teeth  and  to  each  other 


Fig.  8. — Four-Tailed 
Bandage  for 
Fracture  op  the 
Inferior  Maxilla. 


22  INJURIES  OF  THE  HEAD 

by  threads;  but  no  threads  should  be  placed  around  the  two  teeth 
nearest  the  fracture,  for  they  are  usually  loosened  and  incapable 
of  enduring  the  strain.  In  many  cases  absence  of  teeth,  or  the 
situation  of  the  fracture  far  back,  makes  this  plan  of  treatment 
impossible. 

Fracture  of  the  lower  jaw  may  be  treated  by  means  of  an  in- 
terdental splint.  Success  in  the  use  of  tin's  form  of  apparatus 
depends  not  a  little  upon  the  manual  dexterity  of  the  surgeon.  The 
first  step  is  to  secure  a  good  impression  of  the  teeth  and  gums  of 
the  whole  of  the  lower  jaw.  This  impression  may  readily  be  taken 
by  means  of  modeling  composition  such  as  dentists  use,  and  it  is 
not  at  all  necessary  that  the  fracture  be  reduced  when  the  impres- 
sion is  taken.  It  is  just  as  easy  to  set  the  fracture  in  the  im- 
pression as  it  is  in  the  jaw,  but  the  fracture  must  be  reduced,  of 
course,  before  the  splint  is  applied.  The  impression  should  show 
the  line  of  the  gums  both  inside  and  outside  the  teeth,  and  should 
extend  well  back  to  the  angle  of  the  jaw  on  the  fractured  side. 
From  such  an  impression,  if  well  made,  an  excellent  splint  may 
be  ordered  from  any  dental  manufacturing  house  at  a  cost  of  ten 
dollars  or  more.  Counter-pressure  is  obtained  by  the  four-tailed 
bandage  already  described,  or  the  splint  may  be  pressed  against 
the  lower  jaw  by  mean's  of  a  pad  or  a  bit  of  board  which  is  attached 
to  the  splint  by  a  broad  spring  curling  over  the  chin.  Another  plan 
is  to  fix  wires  in  the  interdental  splint.  These  come  out  at 
the  angles  of  the  mouth  and  turn  backward  along  the  cheeks,  and 
are  bound  together,  the  bandage  passing  beneath  the  jaw.  Pres- 
sure w7ill  be  more  exact  if  a  board  nearly  as  long  as  the  distance 
between  the  wires  is  placed  under  the  jaw.  If  a  splint  of  this 
character  fits  accurately,  it  enables  the  patient  to  open  his  mouth 
and  often  to  chew  soft  food,  if  the  interdental  splint  is  made  to 
fit  both  upper  and  lower  teeth.  In  many  cases,  this  splint  will 
keep  the  broken  bone  in  place  without  the  use  of  a  bandage. 

The  form  of  apparatus  selected  must  be  worn  for  a  month 
or  more,  depending  upon  the  amount  of  tendency  to  displacement 
and  the  rapidity  with  which  the  ends  of  the  bone  unite.  Even  in 
favorable  cases  it  wrill  be  several  weeks  before  the  patient  regains 
the  full  power  of  the  jaw  and  the  ability  to  open  wide  the  mouth. 
If  the  line  of  union  is  a  correct  one,  the  surgeon  need  not  hesitate 
to  promise  complete  restoration  of  function. 


FRACTURES  23 

Complications  of  Fracture  of  the  Lower  Jaw. — Fracture  of  the 
lower  jaw  is  usually  compound  into  the  mouth.  It  is  therefore 
not  surprising  that  infection  sometimes  develops.  In  a  certain 
number  of  cases  this  is  of  mild  character ;  the  pus  which  forms  is 
discharged  into  the  mouth,  the  wound  heals  by  granulation,  and 
the  .union  of  the  fractured  bone,  although  delayed,  is  not  other- 
wise interfered  with.  In  a  good  many  cases,  however,  an  abscess 
forms  which  drains  imperfectly  and  gives  rise  to  pain,  swelling 
and  edema  of  the  neck  and  possibly  fluctuation  below  the  margin 
of  the  jaw.  This  is  an  unfortunate  complication,  since  it  may 
lead  to  a  sequestrum  and  greatly  delay  recovery,  and  possibly 
make  it  necessary  to  perform  one  or  more  operations  to  provide 
drainage  or  remove  dead  bone.  It  is  therefore  important  to  keep 
the  mouth  of  every  patient  as  clean  as  possible  by  the  use  of 
astringent  and  antiseptic  mouth  washes.  If  an  abscess  forms,  it 
should  be  promptly  drained  within  the  mouth  if  good  drainage 
can  be  thus  secured,  and  if  not,  through  an  external  incision. 
Such  an  incision  should  be  parallel  to  the  margin  of  the  jaw,  and 
just  below  it.  If  the  fracture  is  near  the  center  of  the  horizontal 
ramus,  the  possibility  of  division  of  the  facial  artery  or  vein 
should  be  borne  in  mind.  A  drain  should  be  placed  in  the  external 
wound,  but  should  be  of  such  a  character  as  to  favor  the  escape 
of  pus,  and  not  to  prevent  it.  Frequent  irrigation  with  a  solution 
of  peroxide  of  hydrogen  (1:8)  assists  in  keeping  the  wound  free 
from  bacteria.  Meanwhile  treatment  of  the  fracture  itself  should 
be  continued  as  described  above. 

A  sinus  which  has  formed  spontaneously,  or  which  follows  an 
external  incision  for  drainage  usually  lasts  some  weeks.  No  at- 
tempt should  be  made  to  close  the  opening  in  the  skin  until  the 
deeper  portion  of  the  sinus  has  become  filled  by  granulation. 
When  this  takes  place,  the  opening  in  the  skin  will  quickly  close. 

Persistence  of  the  sinus  means  that  some  foreign  material  is 
present :  either  the  loosened  root  of  a  tooth  or  a  sequestrum  of  the 
bone  itself.  The  opening  should  be  enlarged,  such  foreign  mate- 
rial removed,  and  another  period  of  drainage  instituted.  Care 
should  be  taken  not  to  break  up  newly  formed  bone,  which  is  often 
thrown  out. around  the  sequestrum  in  great  abundance  in  cases  of 
compound  fracture  of  the  lower  jaw. 

Non-union  of  the  mandible  is  almost  unknown;  therefore  a 


24  INJURIES   OF  THE   HEAD 

persistent  following  out  of  the  principles  here  outlined  will  lead 
to  complete  restoration.  If  the  resulting  scar  is  unnecessarily  dis- 
figuring by  reason  of  its  close  attachment  to  the  hone,  it  should 
be 'removed  ;  bu1  not  until  some  months  have  elapsed  (p.  47). 

Dislocation  of  the  Jaw. — This  is  a  rare  accident  which 
is  brought  on  by  extreme  gaping  or  laughter.  The  condyloid 
process  on  one  or  both  sides  slips  forward  out  of  its  socket.  It  is 
impossible  to  close  the  mouth,  and  the  pain  due  to  stretching  of 
the  ligaments  is  excessive.  The  patient  should  be  anesthetized 
and  the  jaw  grasped  firmly  with  two  hands,  the  thumbs  of  which, 
well  wrapped  about  with  bandage,  are  placed  upon  the  molar  teeth. 
Pressure  downward  and  then  backward  will  restore  the  bone  to 
its  correct  position.  In  some  persons  dislocation  of  the  jaw  takes 
place  easily,  owing  to  abnormal  laxity  of  the  ligaments.  Under 
these  circumstances  reduction  is  readily  accomplished  without  an 
anesthetic.     Xo  after  treatment  is  necessary. 

There  are  certain  long  standing  cases  of  unreduced  dislocation 
of  the  jaw  which  cannot  be  reduced  in  the  manner  described,  and 
for  which  resection  of  the  articular  portion  of  the  bone  has  been 
advised,  or  the  bone  may  sometimes  be  dragged  into  place  by  a 
specially  contrived  hook  which  is  inserted  through  a  small  wound 
in  the  cheek  and  is  passed  around  the  neck  of  the  jaw. 

Subluxation. — A  few  young  men  and  girls — especially  the  lat- 
ter— complain  of  a  partial  dislocation  of  one  or  both  maxillary 
articulations  every  time  the  mouth  is  opened.  This  trouble  occurs 
at  the  period  of  development  of  the  wisdom  teeth,  and  in  most 
cases  it  is  due  to  the  lack  of  space  for  the  orderly  growth  of  the 
tooth.  If  the  tooth  grows  crooked,  or  if  swelling  accompanies  its 
eruption,  the  normal  action  of  the  muscles  which  open  and  close 
the  jaw  is  interfered  with.  Suppuration  about  the  wisdom  tooth,  or 
even  a  blow  on  the  jaw,  may  cause  similar  symptoms. 

The  pain  is  usually  slight.  The  patient  is  annoyed  by  its 
persistence,  or  by  an  uncomfortable  slipping  of  the  jaw,  or  by 
its  slipping  with  a  click  loud  enough  to  be  heard  by  others  when 
the  patient  is  eating.  In  the  developmental  cases,  spontaneous 
cure  often  results  in  some  months.  If  the  wisdom  tooth  is  much 
out  of  line,  or  is  decayed,  it  should  be  removed.  Pain  is  often 
relieved  by  counterirritants,  but  great  care  should  be  exercised 
not  to  permanently  stain  the  skin  by  their  use. 


CHAPTEK    II 

INFLAMMATIONS   OF  THE   HEAD 

EFFECTS   OF   HEAT  AND   COLD 

Burns. — The  burns  of  the  head  which  the  surgeon  is  called 
upon  to  treat  are  not  usually  very  deep.  The  scalp  is  protected  by 
hair,  and  if  flames  or  steam  rise  into  the  face  sufficiently  to  burn 
deeply,  they  will  usually  be  inhaled  and  produce  fatal  internal 
injury.  Most  of  the  deeper  burns  of  the  face  are,  therefore,  the 
result  of  a  gas  explosion  or  the  electric  flash  caused  by  short  cir- 
cuiting. The  importance  of  avoiding  a  scar  is,  of  course,  very 
great,  so  that  slight  burns  should  be  carefully  attended  to. 

Burns  have  been  variously  classified  according  to  the  depth  to 
which  the  tissue  is  destroyed.  For  practical  purposes,  they  may 
all  be  placed  in  three  classes. 

Burns  of  the  First  Degree. — The  symptoms  are  swelling, 
redness,  and  tenderness  of  the  skin.  There  is  no  visible  destruc- 
tion even  of  the  epidermis,  although  this  usually  peels  off  in  strips 
a  few  days  later.  A  familiar  example  is  a  mild  sunburn.  There 
is  increased  redness  of  the  burned  area  for  a  week  or  more,  but  no 
permanent  scar. 

Treatment  of  Burns  of  the  First  Degree. — The  chief 
indication  for  treatment  is  the  relief  from  pain.  This  is  best  accom- 
plished by  smearing  the  surface  with  one  of  the  lighter  ointments 
which  contains  a  considerable  amount  of  water,  such  as  rose  water 
ointment,  or  one  of  the  ointments  sold  under  the  names  of  Let- 
tuce Cream,  Cucumber  Cream,  etc.  Cow's  cream  is  excellent  for 
the  purpose.  Recovery  promptly  follows  the  application  of  any 
non-irritating  substance. 

Burns  of  the  Second  Degree. — Much  of  the  epidermis 
within  the  burned  area  is  destroyed.  There  are  blisters  either  full 
of  serum  or  collapsed,  or  the  injured  epidermis  may  have  been 
more  or  less  removed.     Hairs  within  the  burned  area  are  also 

25 


26  lXI'i. ANIMATIONS   OF  THE    HEAD 

burned  away.  There  is  redness,  swelling,  and  tenderness,  and  a 
lucre  or  less  free  oozing  of  serum,  and  possibly  of  some  blood. 
Repair  in  this  class  of  burns  takes  longer  than  in  burns  of  the  first 
degree,  but  no  slough  of  the  true  skin  occurs.  If  the  whole  thick- 
ness of  the^epiderma]  layer  is  here  and  there  destroyed,  these  areas 
•ire  very  small  and  are  rapidly  covered  by  spreading  of  the  deeper 
layer  of  epithelial  cells.  Then'  is,  therefore,  no  permanent  scar. 
Redness  will  persist  longer  than  in  burns  of  the  lirst  degree,  pos- 
sibly for  a  month  or  more. 

Treatment  oe  Burns  oe  the  Second  Degree. — The  chief 
indication  for  treatment  is  the  relief  of  pain.  The  permanent 
result  is  certain  to  be  good.  There  are  four  plans  of  treatment: 
One  is  to  apply  a  dressing  soaked  with  oil  or  spread  with  ointment 
in  order  to  protect  the  injured  surface  from  the  air  and  from 
changes  in  temperature.  A  second  plan  is  to  cover  the  burn  with 
strips  of  rubber  tissue  or  with  gauze  wet  with  normal  saline  solu- 
tion. The  third  plan  is  to  treat  the  burned  area  with  an  antiseptic 
dressing,  which  may  be  allowed  to  dry  or  which  may  be  kept  moist. 
The  fourth  plan  is  to  leave  the  burned  area  exposed  to  the  air  in 
order  that  it  may  dry  up.  Various  dusting  powders  are  employed 
to  further  this  last  plan. 

The  author  favors  the  first  or  the  second  of  these  four  plans, 
believing  that  these  dressings  are  more  comfortable  to  the  patient, 
and  that  they  favor  the  vitality  of  those  portions  of  the  skin  which 
have  been  injured  but  not  destroyed  by  the  burn;  and  because 
such  dressings,  provided  plenty  of  ointment  is  used,  or  plenty  of 
water  if  a  wet  dressing  is  employed,  can  be  removed  with  less  pain 
and  damage  than  other  dressings  which  are  allowed  to  dry  out. 
Powders  are  objectionable,  since  they  form,  with  the  exuded  se- 
rum, hard  crusts  which  are  veritable  culture  tubes  for  bacteria. 
It  is  impossible  to  make  or  keep  aseptic  an  area  of  skin  which 
has  been  burned  below  the  superficial  portion  of  the  epidermis. 
Protection  against  infection  depends,  therefore,  on  the  vitality  of 
the  remaining  skin  rather  than  on  the  antiseptic  qualities  of  the 
dressing.  Hence,  the  latter  should  be  soothing  to  the  skin  rather 
than  deadly  to  the  bacteria. 

A  good  exam] ile  of  an  oily  dressing  is  carron  oil,  a  mixture  of 
equal  parts  of  linseed  oil  and  lime  water.  If  this  is  used  the 
gauze  should  be  thoroughly  saturated  with  it,  as  otherwise  the  oil 


BURNS  27 

will  soak  into  the  outer  dry  dressings,  and  the  inner  layers  will 
become  very  firmly  attached  to  the  skin.  For  this  reason  an  oint- 
ment is  preferable  in  most  cases.  A  good  one  is  composed  of  one 
dram  of  boric  acid  to  the  ounce  of  vaseline.  The  ointment  should 
be  sterilized  by  setting  the  jar  which  contains  it  in  a  pan  of  boiling 
water.  It  can,  of  course,  be  sterilized  in  a  steam  sterilizer.  The 
ointment  should  be  used  freely.  A  good  plan  is  to  spread  it  over 
the  burned  area  with  a  spatula,  much  as  one  spreads  butter  with  a 
knife.  Dry  gauze  can  then  be  applied  in  pieces  small  enough  to 
fit  the  part,  and  the  dressing  fixed  by  a  loose  gauze  bandage. 

The  principle  of  the  normal  saline  solution  when  used  as  a 
dressing  for  a  burn  is  the  same  .as  when  used  as  a  dressing  for 
a  skin  graft.  It  is  to  reproduce  as  far  as  possible  the  normal 
surroundings  of  growing  epithelium.  If  this  plan  is  adopted,  the 
burned  area  should  be  immersed  in  a  saline  solution,  or  lightly 
sponged  with  swabs  saturated  with  the  same.  It  is  then  covered 
with  several  thicknesses  of  gauze  saturated  with  saline,  and  evapo- 
ration is  prevented  by  covering  the  whole  with  a  sheet  of  gutta- 
percha tissue,  or  strips  of  gutta-percha  tissue  may  be  applied 
directly  to  the  burned  surface,  and  these  in  turn  be  covered  by  the 
wet  gauze.  When  the  dressing  is  applied  in  this  manner,  a  sheet 
of  impervious  material  may  be  applied  externally,  or  this  may  be 
omitted  and  the  gauze  kept  wet  by  more  frequent  saturation  with 
saline  or  boiled  water. 

Picric  acid  is  recommended  by  those  who  favor  antiseptics  in 
the  treatment  of  burns  of  the  second  degree.  Gauze  is  saturated 
with  a  one  per  cent  solution,  either  before  or  after  it  is  applied  to 
the  burned  surface.  This  dressing  is  supposed  to  control  the  pain, 
but  I  have  seen  patients  suffer  severely  after  its  employment.  It 
has  a  tendency  to  dry  up  the  exudate,  so  that  in  many  cases  burns 
treated  in  this  way  are  greatly  improved  in  appearance.  The  in- 
tense yellow  color  of  the  picric  acid  stains  the  clothing. 

A  mild  antiseptic  solution  suitable  for  use  in  burns  of  the 
second  as  well  as  of  the  third  degree,  is  a  four  per  cent  solution 
of  aluminum  acetate.  The  gauze  should  be  saturated  with  it,  and 
then  kept  wet  by  the  addition  of  sterile  water  from  time  to  time. 

If  it  is  decided  to  treat  the  burn  by  the  dry  method,  it  may  be 
left  exposed  to  the  air  or  cleansed  and  dusted  with  a  powder,  such 
as  bismuth  subnitrate,  or  bismuth  subgallate,  or  nosophen. 


28  INFLAMMATIONS    OF  THE   HEAD 

Burns  of  the  Third  Degree. — Portions  of  the  corium,  and 
possibly  still  deeper  structures  have  been  destroyed  by  the  heat.  It 
is  easy  to  be  misled  in  this  matter  by  the  early  appearance  of  the 
skin.  In  a  burn  of  the  first  or  second  degree  the  affected  skin  is 
red  from  the  congestion  of  the  vessels  in  it.  If  the  vitality  of  the 
corium  is  destroyed,  the  blood  cannot  circulate  through  its  vessels, 
and  the  skin  will  therefore  appear  white.  The  difference  between 
tli is  skin  and  normal  skin  is  easily  recognized  if  one  looks  for 
changes  in  color  due  to  pressure  made  upon  it.  Such  changes 
will,  of  course,  be  wanting  in  the  dead  skin.  Furthermore,  such 
a  white,  dead  area  will  invariably  be  surrounded  by  a  hyperemic 
zone  in  which  the  burn  is  only  of  the  second  degree.  I  have  known 
several  instances  in  which  intelligent  physicians  overlooked  a  burn 
of  the  third  degree,  being  misled  by  the  lack  of  redness  of  the 
skin.  This  dead  skin  will,  of  course,  slough,  and  in  time  will 
become  entirely  loose.  During  this  process,  which  sometimes  takes 
two  weeks  or  more,  there  is  danger  that  the  slough  will  interfere 
with  the  exit  of  underlying  pus. 

Treatment  of  Burns  of  the  Third  Degree. — We  have, 
then,  in  burns  of  the  third  degree,  three  indications  for  local  treat- 
ment— the  relief  of  pain,  protection  of  the  injured  but  living  tis- 
sues, and  drainage  of  any  pus  pockets  which  may  form.  A  moist 
antiseptic  dressing  best  fulfils  the  requirements.  In  most  cases 
morphine  should  be  given  either  hypodermically  or  by  mouth  dur- 
ing the  first  twenty-four  hours.  Few  persons  can  sleep  without  an 
opiate  the  first  night  after  a  burn,  even  if  they  can  endure  the 
pain  while  awake. 

The  moist  dressing  should  be  applied  warm  and  kept  warm. 
The  gauze  may  be  saturated  with  aluminum  acetate,  as  mentioned 
above,  or  boric  acid,  or  any  other  feeble  antiseptic.  The  dressing 
should  be  kept  constantly  moist,  and  in  some  instances  a  continu- 
ous bath  is  desirable. 

Frequent  dressings  are  to  be  avoided,  but  if  the  dressings  be- 
come saturated  with  pus  and  serum,  the  comfort  of  the  patient  is 
usually  promoted  by  changing  them.  Sloughs  should  be  cut  away 
as  soon  as  they  loosen,  but  not  before.  If  a  large  area  is  burned, 
the  central  portions  of  the  skin  may  loosen  before  the  edges.  If 
so,  incisions  should  be  made  through  the  slough  or  portions  of  it 
excised  to  permit  free  escape  of  pus  and  secretions. 


BURNS  29 

The  repair  after  a  burn  of  the  first  or  second  degree  is  accom- 
plished by  the  normal  growth  of  the  epidermis.  In  every  burn  of 
the  third  degree  the  removal  of  the  sloughs  is  accomplished  by  the 
growth  of  granulations  beneath  them.  These  granulating  areas 
must  be  covered  by  the  lateral  growth  of  the  epithelial  cells,  either 
from  the  edge  of  uninjured  skin,  or  from  islands  of  epithelium 
which  have  been  left,  or  from  the  epithelium  which  lines  the  fat 
and  sweat  glands.  This  new  epithelium  at  first  has  no  color  of 
its  own,  and  simply  looks  like  a  dark  red  glaze  over  parts  of  the 
granulating  surface.  Later,  as  the  epithelial  cells  multiply,  a 
whitish  appearance  results.  It  will  be  evident,  therefore,  in  two 
or  three  weeks  whether  the  burned  area  will  become  covered  with 
epithelium  within  a  reasonable  time.  An  epithelial  edge  will  grow 
about  an  eighth  of  an  inch  a  week.  A  granulating  area,  therefore, 
which  is  an  inch  in  its  smallest  diameter,  will  require  a  month  for 
its  complete  repair.  Areas  larger  than  this,  and  which  are  with- 
out epithelial  islands  should  be  skin-grafted  (see  Chapter  XX). 

There  is  one  other  thing  to  be  borne  in  mind  during  the  repair, 
and  that  is  the  possibility  of  cicatricial  contraction.  This  can  be 
avoided  to  a  certain  extent  by  the  judicious  use  of  plaster  ban- 
dages and  splints  to  keep  the  burned  area  fully  extended  during 
the  healing  process;  but  a  far  better  means  of  prevention  is  the 
early  covering  of  the  granulating  surface  with  pedicled  flaps,  or 
when  this  is  not  practical,  with  Thiersch,  or  better,  with  Wolfe 
grafts.  In  this  way  the  amount  of  scar  tissue  is  kept  at  a  mini- 
mum and  the  power  of  contraction  will  be  slight. 

Sunburn. — This  injury,  though  not  serious,  should  be  pre- 
vented many  times  when  it  is  not.  Before  exposure  to  the  rays 
of  the  sun  the  skin  should  be  rubbed  with  cold  cream  or  some  sim- 
ple ointment,  such  as  boracic  acid  ointment,  and  when  the  skin 
shows  the  first  pink  color,  it  should  be  covered  with  clothing.  If 
one  waits  until  the  sensation  of  burning  is  present,  the  mischief 
will  have  been  accomplished.  The  treatment  of  sunburn  is  that 
of  a  burn  of  the  first  degree.    Washing  with  soap  is  to  be  avoided. 

Sunburn  of  the  lip  is  very  annoying  because  it  takes  from  one 
to  two  weeks  for  recovery.  This  is  because  the  thinner  epithelium 
in  the  burned  area  is  totally  destroyed,  and  the  little  ulcer  which 
results  must  heal  entirely  by  growth  of  epithelium  from  its  edges, 
at  the  rate  of  one-eighth  of  an  inch  per  week. 


30  INFLAMMATIONS    {)[<    THE    HEAD 

X-Ray  Burn. — Exposure  to  the  X-ray  in  some  cases  for  a  few 
minutes  only,  produces  a  redness  of  the  skin  which  somewhat  re- 
sembles sunburn.  It  does  not,  however,  appear  until  some  hours 
after  the  exposure.  If  the  exposure  is  frequently  repeated,  an 
ulcer  may  form. 

The  milder  lesions  quickly  disappear,  and  require  no  other 
treatment  than  soothing  applications.  The  ulcers  are  often  very 
painful.  Ointments  containing  cocain,  morphine,  menthol,  or 
orthoform  should  be  tried.  Stelwagon  recommends  curettage  and 
skin-grafting  in  obstinate  cases. 

Frostbite. — The  cars,  cheeks,  and  nose  are  the  parts  of  the 
head  most  often  frozen.  If  the  part  is  still  frozen  wdien  t In- 
patient is  first  seen,  it  should  be  rubbed  lightly  in  the  cold 
until  the  circulation  is  reestablished,  in  order  to  avoid  a  violent 
reaction. 

Frostbite  of  the  head  requiring  surgical  treatment  is  almost 
always  confined  to  the  ears.  The.  symptoms  of  cyanosis,  swelling, 
pain,  and  tenderness  are  here  well  marked.  Occasionally  blisters 
form ;  but  gangrene  is  uncommon,  at  least  in  this  latitude. 

Various  applications  have  been  recommended  for  frostbite. 
The  good  effect  of  treatment  seems  to  be  due  merely  to  the  main- 
tenance of  an  even  temperature  which  facilitates  the  flow  of  blood 
to  the  part.  Moreover,  the  dressing  protects  the  ear  from  sudden 
changes  in  temperature.  Any  astringent,  or  a  simple  ointment, 
such  as  one  containing  tannic  acid  or  ichthyol,  spread  in  a  thick 
layer  upon  gauze  applied  to  the  ear  and  covered  with  a  layer  of 
cotton,  forms  a  satisfactory  dressing. 

If  a  portion  of  the  ear  is  gangrenous,  it  should  not  be  removed 
until  a  line  of  demarcation  is  well  established.  It  may  then  be 
seen  that  gangrene  does  not  extend  deeper  than  the  skin,  or  pos- 
sibly the  epidermis.  (Compare  gangrene  of  the  extremities  from 
frostbite,  Chapters  XV  and  XVIII.) 

Dermatitis. — Sunburn  and  frost-bite  are  forms  of  dermatitis 
due  to  heat  and  cold.  Dermatitis  may  also  be  due  to  traumatism, 
the  treatment  for  which  is  essentially  the  same  as  that  given  for 
sunburn.  In  other  cases,  dermatitis  follows  the  unwise  use  of 
drugs  externally  or  internally,  while  a  very  common  form  of  der- 
matitis is  due  to  contact  with  poison  ivy.  These  have  the  general 
name  of  dermatitis  venenata  if  due  to  an  external  application ;  if 


HERPES  31 

due  to  an  ingested  drug  or  poison,  the  name  dermatitis  medica- 
mentosa is  used. 

Iodoform,  mercury,  carbolic  acid,  cantharides,  dyestuffs,  etc., 
will  poison  certain  skins.  There  may  be  simply  a  redness  and 
burning,  or  there  may  be  a  profuse  eruption  of  vesicles.  In  ivy 
poisoning  these  vesicles  are  of  various  sizes,  and  a  number  of  small 
ones  often  merge. 

In  most  cases  of  dermatitis,  as  soon  as  the  cause  is  removed 
there  is  a  prompt  recovery.  Treatment  consists,  therefore,  of 
soothing  applications,  such  as  a  two  per  cent  solution  of  boracic 
acid,  or  the  application  of  a  simple  ointment.  Larger  vesicles 
should  be  punctured  and  their  contents  expressed.  In  some  cases 
an  opiate  is  required.  If  the  eruption  is  due  to  the  ingestion  of  a 
drug,  the  drug  should,  of  course,  be  stopped  and  a  diuretic  and 
cathartic  should  be  given. 

ACUTE   INFLAMMATIONS 

There  are  four  common  skin  lesions  of  an  inflammatory  nature 
frequently  found  upon  the  face,  with  the  diagnosis  and  treatment 
of  which  every  physician  should  be  familiar.  They  are  urticaria, 
herpes,  impetigo,  and  acne.  A  brief  description  of  these  four  dis- 
eases is  given  here  because  of  their  acute  character,  as  well  as  to 
differentiate  them  from  forms  of  inflammation  in  the  skin  gener- 
ally considered  surgical. 

Urticaria. — Urticaria  is  a  form  of  eruption  greatly  resem- 
bling the  bites  of  insects.  Indeed  these  bites  are  classed  as  lesions 
of  urticaria  by  some  writers.  Other  external  irritants,  and  vari- 
ous articles  of  food,  especially  shellfish,  pork  products,  and  straw- 
berries, will  produce  urticaria  in  some  persons.  The  lesions  come 
up  quickly  and  usually  subside  in  a  few  hours. 

A  saline  cathartic  should  be  given,  or  under  certain  circum- 
stances an  emetic.  The  affected  skin  should  be  bathed  with  a 
lotion,  usually  containing  one  or  two  per  cent  of  carbolic  acid,  to 
relieve  the  itching.  Three  ounces  of  alcohol,  three  ounces  of  cam- 
phor water,  and  one  dram  of  carbolic  acid,  make  a  good  lotion  for 
the  purpose. 

Herpes. — The  lesion  of  simple  herpes,  or  fever  sore,  is  a 
group  of  half  a  dozen  vesicles,  each  of  which  is  about  as  large  as 


32  INFLAMMATIONS   OF   THE   HEAD 

a  pin-head.  These  contain  at  first  serum,  hut  later  the  fin  id  may 
become  purulent.  By  drying,  a  crust  results  which  falls  off  with- 
out leaving  a  permanent  scar.  The  lesions  are  usually  found 
either  upon  the  face  or  the  genitals.  They  are  often  seen  on  the 
lips  in  the  beginning  of  acute  disease,  especially  acute  inflamma- 
tions of  the  respiratory  tract. 

Any  one  group  of  vesicles  lasts  only  a  few  clays,  but  new 
vesicles  may  form  in  the  vicinity.  A  good  plan  is  to  paint  the 
affected  skin  every  two  or  three  hours  with  spirits  of  camphor, 
or  with  tincture  of  benzoin.  Carbolic  salve  may  be  applied  to 
the  surrounding  skin  in  the  hopes  of  preventing  new  lesions 
from  forming.  When  a  crust  has  formed,  cold  cream  may  be 
applied. 

Impetigo. — Impetigo  contagiosa  is  an  acute  contagious  dis- 
ease, the  lesions  of  which  are  usually  found  upon  the  face.  There 
is  first  noticed  a  number  of  vesicles  which  soon  become  pustules,  and 
which  may  coalesce.  Crusts  form,  dry  up,  and  fall  off,  leaving  no 
permanent  scar  because  the  lesion  is,  in  most  instances,  confined 
to  the  more  superficial  portion  of  the  skin.  For  the  same  reason, 
there  is  little  induration  about  any  pustule.  Successive  crops  of 
vesicles  appear,  especially  if  the  patient  breaks  the  formed  blisters 
or  pustules  by  scratching. 

The  essentials  of  treatment  are  cleanliness  and  antisepsis. 
Blisters  should  be  punctured,  crusts  removed,  and  an  antiseptic 
lotion  or  ointment  applied.  A  good  preparation  is  cold  cream  to 
which  ammoniated  mercury  has  been  added  in  the  proportion  of 
fifteen  grains  to  the  ounce,  or  twenty  grains  of  sulphur  to  the 
ounce.  The  sound  skin  in  the  neighborhood  should  be  sponged 
with  an  antiseptic  solution.  A  good  one  for  the  purpose  is  given 
under  Urticaria. 

Acne. — Acne  is  defined  as  an  inflammatory  disease  of  the 
sebaceous  glands  of  the  face,  chest,  and  shoulders.  It  is  most  dis- 
tressing to  the  patient  when  it  appears  upon  the  face.  It  is  usu- 
ally chronic.  A  careful  examination  of  the  skin  within  the  area 
affected  will  show  that  many  ducts  of  the  sebaceous  glands  are 
blocked  up,  and  contain  sebaceous  material  mixed  with  dust,  hence 
the  common  name  "  blackhead."  Other  obstructed  ducts  are  the 
centers  of  little  red,  inflamed  papules.  Pustules  have  formed 
around  others,  while  there  are  numerous  scars  of  similar  lesions 


CELLULITIS  33 

which  have  healed.  Many  of  these  lesions  run  their  life  history 
without  sufficient  suppuration  to  leave  a  permanent  scar. 

There  are  three  factors  in  the  development  of  acne — blocking 
up  of  the  sebaceous  duct,  presence  of  micro-organisms,  and  a  low- 
ered power  of  resistance  to  these  organisms  on  the  part  of  the 
individual.  Thus,  digestive  disturbances,  the  use  of  irritating 
drugs,  menstrual  irregularity,  and  other  general  causes  exert  a  con- 
siderable influence.  Acne  is  especially  common  between  the  ages 
of  fifteen  and  twenty-five. 

Treatment. — Both  general  and  local  treatment  should  be  em- 
ployed. Errors  in  diet  should  be  corrected,  out-of-door  exercise 
encouraged,  and  such  other  measures  instituted  as  will  tend  to 
improve  the  patient's  general  condition.  Tree  action  of  the  bowels 
should  be  secured.  Tonics  are  helpful,  but  no  drugs  should  be 
given  which  are  likely  to  upset  the  stomach. 

Local  treatment  is  most  important.  The  affected  part  should 
be  washed  every  night  with  very  hot  water,  and  as  strong  a  soap 
as  the  skin  will  tolerate.  Tincture  of  green  soap  acts  well  in  many 
cases.  The  soap  should  be  thoroughly  removed  by  hot  water,  the 
skin  dried,  and  a  stimulating  antiseptic  ointment  rubbed  into  it. 
In  the  morning  this  ointment  should  be  washed  away  with  soap 
and  warm  water,  the  skin  dried,  and  a  soothing  ointment  rubbed 
into  it.  Cold  cream  answers  the  purpose  very  well.  Only  a  small 
quantity  should  be  used,  and  any  excess  wiped  away  with  a  soft 
cloth.  A  good  stimulating  ointment  is  benzoated  lard  to  which 
has  been  added  precipitated  sulphur  in  the  strength  of  one  or  two 
drams  to  the  ounce.  Instead  of  the  ointment  a  stimulating  lotion 
may  be  employed,  such  as  one  composed  of  four  drams  of  pre- 
cipitated sulphur,  two  drams  of  alcohol,  thirty  minims  of  glycerin, 
and  four  ounces  of  water.  The  strength  of  the  application  used 
must  be  varied  to  suit  different  skins,  and  it  is  often  of  advantage 
to  change  the  formula  employed  from  time  to  time.  There  are 
many  of  these  given  in  every  book  on  dermatology. 

Individual  acne  pustules  should  be  stabbed  with  a  fine  lancet 
or  a  three  sided,  straight  glover's  needle,  and  their  contents  gently 
expressed. 

Acne  hypertrophica  is  described  with  new  growths  on  page  83. 

Cellulitis. — Cellulitis  of  the  head,  whether  it  affects  the  hairy 
or  smooth  skin,  presents  the  usual  characteristics :  namely,  edema, 


34 


INFLAMMATIONS   OF   THE    HEAD 


heat  and  redness,  and,  especially  if  pus  is  present,  there  will  be 
pain  on  pressure.  The  scratch  or  slight  wound  through  which  the 
infection  entered  can  usually  be  found.  Often  it  is  covered  with 
a  crust,  beneath  which  will  be  found  a  drop  or  two  of  pus.  Two 
questions  are  of  importance.  Is  the  cellulitis  due  to  erysipelas? 
Is  there  a  hidden  focus  of  pus  ?  The  distinguishing  marks  of  ery- 
sipelas are  given  below.  The  presence  of  pus  may  usually  be 
known  by  a  greater  tension  of  the  swollen  skin,  and  the  pain  which 
pressure  causes  at  this  point.  If  there  is  an  abundance  of  pus 
fluctuation  is  a  valuable  sign,  but  it  is  unobtainable  at  an  early 
stage.     ISTote  the  enlargement  of  regional  lymph  glands.     They 

may    suppurate    also    in 
some  cases. 

Treatment. — If  the 
diagnosis  is  doubtful,  or 
if  pus  has  been  found 
and  evacuated,  a  moist 
antiseptic  dressing 
should  be  applied  and 
kept  wet.  ]STo  gutta- 
percha tissue,  nor  other 
impervious  material 
should  be  applied  in  such 
a  manner  that  evapora- 
tion is  prevented.  Any 
mild  antiseptic  solution 
may  be  used,  such  as 
aluminum  acetate,  four 
per  cent ;  bichlorid  of 
mercury,  1 : 2,000  ;  creo- 
lin,  1:  200,  or  one  of 
the  proprietary  articles, 
such  as  borolyptol,  1 :  4. 
The  edge  of  the  cellulitis 
should  be  marked  with 
an  indelible  pencil  or  with  nitrate  of  silver,  and  the  temperature 
and  pulse  recorded  every  three  hours.  Examination  on  the  fol- 
lowing day  will  determine  whether  the  case  is  a  simple  cellulitis, 
or  erysipelas,  or  whether  the  symptoms  are  due  to  hidden  pus. 


Fig.  9. — Necrosis  and  Slough  of  Skin  Due  to 
Cellulitis. 


ERYSIPELAS  35 

The  severe  effect  of  a  peculiarly  localized  cellulitis  is  shown 
in  Figure  9.  The  inflammation  showed  no  tendency  to  spread,  and 
no  pus  was  present,  but  there  was  a  considerahle  necrosis  of  the 
skin  resulting  in  the  small  ulcer  shown  in  the  photograph.  Staphy- 
lococci were  present  in  the  tissues  and  the  discharge. 

Erysipelas. — The  face  is  the  most  common  seat  of  erysipelas. 
It  usually  begins  on  one  side  of  the  nose  as  a  dark  pink  blush. 
The  affected  skin  is  slightly  edematous,  so  that  the  margin  of 
the  affected  area  is  raised.  This  edge  spreads  at  an  appreciable 
rate,  an  inch  or  more  a  day,  though  not  equally  fast  in  all  direc- 
tions. There  is  often  pain  in  the  affected  part,  and  the  constitu- 
tional symptoms  are  out  of  proportion  to  the  extent  of  the  skin 
involved.  There  is  usually  an  initial  chill,  and  the  temperature 
is  commonly  above  102°  every  afternoon  as  long  as  the  inflamma- 
tion is  spreading  in  the  skin.  The  infection  enters  the  skin 
through  some  scratch  or  cut,  which  can  usually  be  found  if  looked 
for.  In  the  case  of  facial  erysipelas  this  break  in  the  skin  is  usu- 
ally to  be  found  inside  of  the  nose.  The  patient  will  often  remem- 
ber to  have  forcibly  removed  some  crust  from  the  nose  a  day  or 
two  days  previous  to  the  attack. 

Treatment. — Compresses  wrung  out  of  a  five  per  cent  solu- 
tion of  carbolic  acid  in  equal  parts  of  alcohol  and  camphor  water 
will  be  found  agreeable  to  the  patient,  and  may  assist  in  limiting 
the  spread  of  the  inflammation.  The  more  radical  method  of  em- 
ploying carbolic  acid  is  to  paint  the  skin  immediately  in  advance 
of  the  inflammation  with  the  liquid  carbolic  acid,  ninety-five  per 
cent.  If  the  skin  is  at  once  wiped  off  with  pure  alcohol  no  injuri- 
ous caustic  action  of  the  acid  will  result.  In  this  way  extension 
of  the  erysipelas  may  sometimes  be  cut  short;  but  those  who  have 
the  opportunity  of  treating  a  large  number  of  cases  of  erysipelas 
usually  doubt  the  curative  power  of  any  application  whatever. 

If  abscesses  form,  they  should  be  incised.  The  general  condi- 
tion of  the  patient  should  be  watched.  .  Laxatives,  light  or  fluid  diet, 
and  possibly  stimulants,  are  the  essentials  of  treatment.  As  ery- 
sipelas is  conveyed  from  one  patient  to  another  by  contact,  the  sur- 
geon should,  if  possible,  avoid  touching  the  patient  or  his  clothes, 
and  should  wash  and  disinfect  his  hands  at  the  close  of  his  visit. 
Similar  precautions  should  be  observed  by  the  nurse  or  attendant. 
It  is  a  good  plan,  if  the  patient  is  not  too  ill,  to  let  him  make  the 


36  INFLAMMATIONS  <>F  THE  HEAD 

applications  himself,  thereby  Lessening  the  risk  of  infecting  some 
one  else. 

Boil,  or  Furuncle. —  The  face  is  a  common  seat  for  boils, 
which  do  not,  however,  reach  a  large  size,  for  the  reason  that  the 
skin  is  thin  and  is  well  supplied  with  blood.  Kvery  effort  should 
be  made  to  cut  short  the  infective  process,  because  the  lesion  is  so 
conspicuous,  and  also  to  avoid  the  disfiguremenl  of  a  permanent 
scar. 

The  diagnosis  is  simple.  The  swelling,  redness,  and  tender- 
ness early  attract  the  patient's  attention.  The  only  point  to  be 
decided  is  whether  or  not  pus  has  collected  in  sufficient  amount  to 
make  its  evacuation  desirable.  If  it  shows  as  a  yellow  spot  in  the 
center  of  the  swelling,  the  patient  will  usually  permit  its  evacua- 
tion; and  yet  the  necessity  for  this  is  sometimes  far  greater  when 
the  pus  does  not  lie  so  near  the  surface.  The  presence  of  a  tender, 
tense,  and  well  localized  swelling  in  or  beneath  the  skin,  always 
indicates  a  collection  of  pus  under  these  circumstances. 

Treatment. — The  best  treatment  is  prompt  incision,  to  allow 
the  escape  of  pus  and  necrotic  material.  Specific  directions  for 
opening  boils  and  abscesses  are  given  in  Chapter  XX.  A  minute 
incision  will  often  suffice  for  these  small  boils  of  the  face.  (Com- 
pare the  treatment  of  acne  pustules,  page  33.)  One  should  resist 
the  temptation  to  squeeze  pus  out  of  the  tissues  after  the  incision 
has  been  made,  as  infection  is  often  spread  in  this  manner.  A 
very  short  incision,  say  not  more  than  a  quarter  of  an  inch  in 
length,  which  should  usually  be  crucial  or  T-shaped  to  prevent  the 
rapid  reattachment  of  the  cut  surfaces,  is  long  enough  for  many 
boils  of  the  face  at  an  early  stage. 

In  most  cases  a  minute  drain,  consisting  of  a  loop  of  thread 
or  a  narrow  strip  of  gutta-percha  tissue,  should  be  placed  in  the 
wound  for  twenty-four  or  forty-eight  hours.  A  wet  dressing  greatly 
favors  recovery.  If  it  is  necessary  for  the  patient  to  go  about,  he 
may  cover  the  wound  with  a  bit  of  gauze  and  a  piece  of  rubber 
plaster,  removing  this  once  or  twice  a  day  in  order  to  soak  the 
parts  with  hot  water,  and  at  night  a  large  wet  dressing  should 
be  applied. 

In  some  cases  the  application  of  ninety-five  per  cent  carbolic 
acid  directly  into  the  center  of  the  boil  will  stop  the  process  and 
hasten  the  expulsion  of  the  necrotic  portion.     In  the  case  of  minute 


STYE,   OR  HORDEOLUM  37 

boils,  the  acid  may  be  applied  upon  a  toothpick,  even  though  no 
incision  has  been  made. 

The  general  condition  of  the  patient  should  be  investigated, 
and  necessary  advice  given  concerning  diet  and  exercise.  Laxa- 
tives are  usually  beneficial.  A  tablespoonful  of  brewer's  yeast 
three  times  a  day  before  meals  is  thought  by  many  to  have  a 
specific  action  in  recurrent  cases.  Sulphur  and  its  compounds  may 
also  be  given  with  benefit;  for  example,  half  a  grain  of  sulphid 
of  calcium  twice  a  day. 

Stye,  or  Hordeolum. — A  small  boil  at  the  root  of  an  eyelash 
is  called  a  stye.  If  untreated,  one  of  these  minute  abscesses  re- 
quires several  days  for  its  full  development.  It  often  causes  great 
pain.  Pus  then  escapes  at  the  edge  of  the  lid,  the  pain  is  relieved, 
and  in  several  days  the  swelling  disappears.  There  is  a  strong 
tendency  to  recurrence  of  the  trouble  in  some  other  portion  of  the 
lid,  so  that  it  is  no  uncommon  thing  for  a  person  to  suffer  from 
a  series  of  styes,  one  or  more  developing  at  the  same  time,  the 
whole  series  lasting  possibly  several  weeks. 

Prophylactic  treatment,  which  will  also  sometimes  serve  to 
abort  a  commencing  suppuration,  consists  in  the  application  of  an 
ointment  containing  eight  grains  of  the  yellow  oxid  of  mercury 
to  the  ounce  of  vaseline.  It  is  also  well  to  wipe  the  edges  of  the 
lids  occasionally  with  a  cotton  swab  wet  with  a  1 :  2,000  solution 
of  corrosive  sublimate.  A  formed  abscess  should  be  punctured 
with  a  sharp,  narrow  lancet.  If  the  blade  is  thin  and  very  sharp 
this  is  not  a  very  painful  procedure,  and  no  anesthetic  is  required. 
To  relieve  pain  either  before  or  after  puncture,  hot,  moist  com- 
presses may  be  applied.     Constipation  should  be  corrected. 

Boils  of  the  Nose  and  Ear. — Small  but  very  painful  boils 
form  in  the  skin  or  mucous  membrane  attached  to  the  cartilage  of 
the  ear  or  nose.  Because  of  the  close  attachment  of  these  struc- 
tures, the  pain  caused  by  the  swelling  is  intense.  An  early  incision 
is  therefore  demanded.  Even  the  injection  of  a  local  anesthetic 
is  very  painful.  Hence  a  strong  solution,  say  a  four  per  cent  solu- 
tion of  cocain,  should  be  employed,  and  only  a  minim  should  be 
injected  at  first.  When  this  has  taken  effect,  the  injection  of  the 
amount  necessary  to  benumb  the  area  of  incision  should  be  com- 
pleted. A  moist  dressing  should  be  applied,  or  the  part  should  be 
soaked  with  hot  water  every  hour  or  so,  in  order  to  keep  the  cut 


38 


INFLAMMATIONS   OF   THE   IILAD 


open  until  all  the  discharge  has  made  its  escape.  As  such  boils 
tend  to  recur,  the  affected  area  should  be  .wiped  twice  daily 
with  an  antiseptic  (creolin,  one  per  cent;  bichlorid  of  mercury, 
1:  1,000). 

Abscess. — Suppuration  in  the  deeper  tissues  of  the  face,  the 
result  of  injuries  and  wounds,  is  usually  prevented  by  the  very 

free   blood    supply. 
Abscess  may  form, 
^*  „«  however,   in    the 

1  ^BpPMb,  cheek,   lip, 

Jr     ^^  '  in  the  tongue.  Such 

an  abscess  occurring 
in  the  lip  is  shown 
in  Figure  10. 

Abscess  of  the 
scalp,  or  rather  be- 
neath the  scalp,  of- 
ten follows  the  too 
hasty  suture  of  a 
scalp  wound;  or  it 
may  develop  from 
small  infected 
wounds,  especially 
in  marasmic  chil- 
dren. This  is  not 
to  be  wondered  at. 
While  the  blood  supply  of  the  scalp  itself  is  very  free,  there  is 
just  beneath  it  a  loose  fascia  with  large  spaces  and  few  blood- 
vessels— a  favorable  tissue  for  the  multiplication  of  germs,  once 
they  are  introduced  into  it. 

Diagnosis. — These  abscesses  are  not  difficult  of  recognition. 
The  classic  symptoms  of  heat,  redness,  tenderness,  and  edema  are 
well  marked.  A  small  abscess  in  the  tongue  feels  like  a  buried 
kernel.  An  abscess  of  the  lip  or  cheek  causes  a  very  great  swelling, 
which  may  obscure  the  exact  presence  of  the  pus  until  it  is  revealed 
by  palpation.  An  abscess  beneath  the  scalp  yields  a  distinct  wave 
of  fluctuation. 

Treatment. — The  length  of  the  evacuating  incision  should 
be  determined  by  the  extent  and  nature  of  the  abscess.     In  an 


Fig.  10. — Abscess  of  the  Lip.  Infection  due  to  a  blow 
by  which  the  lip  was  cut  against  the  decayed  incisor 
teeth.      Photograph  six  days  after  the  injury. 


ABSCESS  3(J 

acute,  rapidly  spreading,  suppurative  cellulitis,  incision  should  be 
made  to  extend  at  least  as  far  as  the  visible  pus  formation,  whereas 
it  is  quite  unnecessary  to  apply  the  same  rule  to  the  slowly  form- 
ing abscess  of  a  marasmic  child.  In  the  latter  case  a  small  open- 
ing, equal  to  one-half  the  diameter  of  the  abscess,  is  sufficient  to 
effect  a  cure,  and  thus  hemorrhage  is  lessened  and  considerable 
time  is  saved  in  the  healing  of  the  wound. 

The  cavity  of  the  abscess  should  be  washed  and  wiped  clean 
with  saline  solution  or  sterilized  water  and  moist  cotton  swabs  or 
dry  sterilized  gauze.  It  has  been  commonly  recommended  to  break 
down  any  septa  which  may  exist,  but,  unless  these  interfere  with 
the  thorough  cleansing  of  the  abscess,  they  should  not  be  disturbed, 
as  they  almost  invariably  contain  blood-vessels,  and  if  broken 
down,  hemorrhage  follows  and  blood  clots  are  added  to  the  con- 
tents of  the  abscess  cavity,  and  the  nutrition  of  the  overlying 
skin  is  interfered  with.  Many  abscesses  of  a  sluggish  nature,  if 
emptied  and  cleansed,  will  heal  without  further  suppuration. 
Such  a  result  is  favored  by  the  introduction  of  a  granular  gelatin 
containing  formalin.  This  acts  as  a  drain  and  contains  enough 
formalin  to  retard  suppuration.  Or  the  wound  may  be  kept  open 
by  slender  strips  of  gutta-percha  tissue  or  gauze,  moistened  with  a 
weak  antiseptic  solution. 

Alveolar  Abscess. — A  common  and  often  severe  abscess  of  the 
face  has  its  origin,  as  its  name  indicates,  about  the  root  of  a  de- 
cayed or  broken  tooth.  The  first  sign  of  its  presence  is  almost 
invariably  a  toothache.  This  may  be  due  to  congestion  merely, 
but  a  violent  toothache  indicates  pus  with  far  greater  certainty 
than  most  dentists  are  ready  to  admit.  The  pain  is  at  first  re- 
ferred to  the  affected  tooth;  but  as  the  inflammation  spreads  the 
nerves  leading  to  other  teeth  may  be  pressed  upon,  and  the  pain 
referred  to  those  teeth.  There  are  three  confirmatory  tests  to  deter- 
mine the  exact  location  of  the  suppuration.  Inspection  will  show 
the  greatest  amount  of  swelling  in  the  mucous  membrane  along- 
side of  the  tooth  involved.  Secondly,  if  the  teeth  are  lightly 
tapped  with  a  metal  instrument,  the  patient  can  usually  recognize 
which  one  is  diseased.  In  the  third  place,  palpation  will  usually 
reveal  the  point  at  which  there  is  the  greatest  swelling,  and  this, 
at  least  in  the  early  stages  of  the  trouble,  corresponds  to  the  root 
of  the  affected  tooth. 


40 


[NFL  WIMATInN'S   OF   THE    HEAD 


The  pus  first  forms  between  the  root  of  the  affected  tooth  and 
the  bone  in  which  it  is  placed — that  is  to  say,  in  the  tooth  socket. 
As  the  pus  increases  in  amount  some  of  it  may  work  its  way  to 
the  surface  and  escape  into  the  mouth  alongside  of  the  tooth.     This 


Fig.  11. — Alveolar  Abscess  from  Upper  Incisor  Tooth.  Note  the  site  of  maximum 
swelling  at  the  root  of  the  nose.  This  is  not  a  common  type,  as  the  pus  usually 
breaks  into  the  mouth  early. 


will  relieve  most  of  the  symptoms,  and  aside  from  slight  tender- 
ness, the  only  remaining  ones  may  be  a  little  swelling  and  the 
escape  of  pus  when  the  patient  sucks  the  tooth  or  pressure  is  made 
on  the  gum.  In  most  cases,  however,  absorption  takes  place,  and 
the  swelling  extends  beyond  the  gum  immediately  around  the 
affected  tooth.  This  swelling  will  next  be  noticeable  in  the  face, 
and  its  situation  will  depend,  of  course,  on  the  situation  of  the 
decayed  tooth ;  thus,  if  an  upper  incisor  is  at  fault,  the  swelling 
will  appear  first  at  the  base  of  the  nose  (Fig.  11).  If  the  upper 
bicuspid  or  molar  teeth  are  involved,  the  swelling  may  appear 


ABSCESS 


41 


further  back  in  the  cheek;  whereas  if  one  of  the  lower  teeth  is 
decayed,  the  swelling  will  be  most  marked  just  below  it. 

The  infection  may  travel  still  further,  and  involve  a  lymphatic 
gland.  This  may  be  very  misleading.  The  upper  teeth  drain  into 
lymphatic  glands  situated  at  the  angle  of  and  below  the  lower  jaw. 
If  the  regional  swelling  above  mentioned  is  slight  and  the  first 
prominent  swelling  is  due  to  involvement  of  the  lymphatic  glands 
which  drain  the  sockets  of  the  upper  teeth,  the  most  marked  swelling 
will  then  appear  in  the  vicinity  of  the  angle  of  the  lower  jaw.  It  is 
well  to  bear  these  facts 
in  mind,  lest  finding  a 
swelling  near  the  an- 
gle of  the  lower  jaw, 
one  may  falsely  con- 
clude that  a  lower 
tooth  is  at  fault.  This 
is  what  happened  in 
the  case  of  the  boy 
shown  in  Figure  12,  and 
a  dentist  extracted  a 
sound  lower  tooth.  The 
infective  process  con- 
tinued, of  course,  until 
more  intelligent  treat- 
ment was  instituted. 

If  an  alveolar  ab- 
scess starts  from  one  of 
the  lower  teeth,  the 
situation  of  the  swell- 
ing is  a  more  reliable 
guide  to  the  source  of 
the  infection. 

Course  of  the  Infection. — The  pus  at  the  root  of  the  tooth 
may  work  its  way  out  along  the  tooth  and  discharge  into  the 
mouth.  Or,  it  may  bore  through  the  periosteum,  and  possibly  a 
thin  layer  of  bone,  and  discharge  through  the  gum  a  little  distance 
away  from  the  juncture  of  the  tooth  and  mucous  membrane — say 
a  quarter  of  an  inch.  This  sinus  is  more  often  on  the  outer  than 
on  the  inner  side  of  the  jaw.    With  the  discharge  of  pus  the  acute 


Fig.  12. — Alveolar  Abscess  from  Upper  Molar 
Teeth.  Note  the  site  of  maximum  swelling  at 
level  of  the  lobe  of  the  ear. 


42 


INFLAMMATIONS   OF  THE   11  HAD 


symptoms  subside,  but  unless  the  tooth  is  tilled  or  removed  the 
process  may  repeat  itself. 

The  pus  may  strip  the  periosteum  from  the  maxilla,  rupture 
the  periosteum,  burrow  between  the  mucous  membrane  and  the 
skin,  or  rupture  through  the  shin  externally,  either  in  the  cheek 

or  beneath  the  lower  jaw 
(Figs.  11,  12,  13).  At 
this  advanced  stage  of 
the  process  fluctuation 
can  usually  be  made  out. 
The  lymphatic  glands 
swell  early  in  the  course 
of  the  inflammation,  but 
they  do  not  always  sup- 
purate. "When  they  do 
suppurate,  the  hard 
swelling  which  they 
form  below  the  jaw  be- 
comes fluctuating.  Such 
a  condition,  secondary 
to  infection  from  an  up- 
per tooth,  is  shown  in 
Figure  13. 

If  an  alveolar  abscess 
is  left  to  itself,  its  spon- 
taneous rupture  either 
into  the  mouth  or  ex- 
ternally may  give  tem- 
porary relief  of  symp- 
toms or  even  effect  a 
cure.  Such  relief  is  often  postponed  until  a  portion  of  the  maxil- 
lary bone,  deprived  of  its  periosteum  and  bathed  in  pus,  becomes 
necrotic.  The  sequestrum  thus  formed  will  keep  up  the  suppura- 
tion. If  a  patient  is  examined  in  this  stage  he  will  have  a  general 
hard  swelling,  not  easily  indented  by  pressure  with  the  finger, 
and  which  varies  in  size  according  to  the  drainage  or  lack  of  it 
through  the  existing  sinus.  The  decayed  tooth  which  was  the 
cause  of  the  trouble  may  or  may  not  be  recognized.  Not  infre- 
quently  the  patient  has  had  it  removed  too  late  to  stop  the  suppu- 


Fig.  13. — Alveolar  Abscess  from  Upper  Tooth, 
Secondary  in  Lymphatic  Glands.  The  max- 
imum swelling  is  beneath  the  lower  jaw.  This 
is  also  the  site  of  swelling  in  cases  of  alveolar 
abscess  of  the  lower  teeth,  without  glandular 
involvement. 


ABSCESS 


4a 


ration,  as  the  bone  has  already  become  necrotic.  In  other  cases 
several  decayed  teeth  are  present,  but  no  longer  sensitive,  so  that 
it  may  be  difficult  to  decide  which  one  has  caused  the  trouble. 

A  probe  passed  into  the  sinus  may  or  may  not  touch  bare  bone. 
The  positive  result  of  such  examination  is  worth  more  diagnos- 
tically  than  a  negative  result.  Furthermore,  if  bone  is  bare  under 
such  circumstances  it  is  almost  certainly  dead.  If  necrotic  bom- 
exists  the  probe  may  fail  to  touch  it  because  the  sinus  is  tortuous. 
The  sequestrum  usually  lies  to  the  inner  side  of  the  lower  jaw, 
and  the  sinus  passes  beneath  the  jaw  and  reaches  the  surface  of 
the  face  on  the  outer  side  of  the  jaw.     It  is  not  surprising  if  so 


Fig.  14. — Recurrent  Alveolar  Abscess.     Duration,  twenty-five  days. 


badly  drained  an  abscess  recurs  from  time  to  time.     Such  an  ex- 
perience was  that  of  the  patient  shown  in  Figure  14. 

If  the  sequestrum  is  a  large  one,  two  or  more  sinuses  may 
exist.  In  such  a  case  a  part  of  the  swelling  which  exists  is  due 
to  the  formation  of  new  bone.  The  periosteum  of  the  lower  jaw 
is  abundantly  supplied  with  blood,  and  does  not  die  easily.     If 


44 


INFLAMMATIONS   OF  THE   HEAD 


it  is  stripped  up  from  the  old  bono  by  the  pus  it  immediately  be- 
gins  to  form  new  bone,  so  that  in  long  standing  cases  the  removal 
of  the  sequestrum  may  be  rendered  difficult  by  the  thick  shell  of 
new  formed  bone  which  surrounds  it. 

Another  possible  termination  of  an  acute  abscess  is  a  persistent 
sinus.     So  long  as  this  suffices  to  carry  away  the  slight  discharge, 

it  will  prevent  the  re- 
formation of  an  ab- 
scess. Usually,  how- 
ever, the  drainage 
obtained  in  this  man- 
ner is  imperfect, 
swelling  or  granula- 
tions block  the  sinus, 
edema  reappears,  and 
if  the  sinus  is  not  re- 
opened another  abscess 
forms.  Such  a  sinus 
giving  imperfect  drain- 
age existed  in  the  Chi- 
nese patient  shown  in 
Figure  15.  The  per- 
sistent discharge  is  an 
indication  of  the  exist- 
c  nee  of  dead  bone  or 
a  decayed  root  of  the 
tooth. 

A  continued  swell- 
ing is  usually  an  indi- 
cation of  decay  of  the 
root  of  the  tooth  or  of  the  adjacent  bone;  there  are  also  cases 
in  which,  although  no  sequestrum  can  be  made  out  and  no  pus 
escapes  externally,  the  irritation  about  the  roots  of  the  affected 
tooth  is  sufficient  to  form  a  chronic  swelling.  Possibly  in  such  a 
case  there  may  be  a  little  suppuration  which  constantly  makes  its 
escape  into  the  mouth.  Figure  16  shows  a  patient  who  gave  a  his- 
tory of  continued  hard  swelling  long  after  the  active  suppuration 
had  ceased.  As  long  as  such  a  patient  retains  the  roots  of  the  de- 
cayed tooth  he  is  exposed  to  a  recurrence  of  the  acute  suppuration. 


Fig.  15. — Chronic  Alveolar  Abscess  from  De 
cayed  Tooth,  of  Seven  Months'  Duration 
The  abscess  was  lanced,  but  a  sinus  persisted. 


ABSCESS 


45 


Finally,   alveolar  abscess  may  lead  to  the  development  of  a 
malignant  growth,  as  shown  in  Figure  17. 

Treatment. — Treatment  at  any  stage  of  an  alveolar  abscess, 
to  be  considered  intelligent,  must  be  directed  toward  removal  of 
the  cause.  If  a  toothache  is  due  simply  to  congestion,  a  local  irri- 
tant, such  as  oil  of  cloves,  chloroform,  etc.,  with  or  without  the 
internal  administration  of  morphine  or  some  other  anodyne,  may 
be  considered  appropriate  treatment.  If,  however,  the  toothache 
is  due  to  an  inflammation  about  the  root  of  a  tooth,  it  must  be 
looked  upon  as  a  real  infection,  similar,  for  example,  to  a  cellu- 
litis preceding  from  an  unclean  sliver  in  the  finger.  The  site  of 
the  infection  should  be 
thoroughly  exposed  and 
drained  so  that  absorp- 
tion of  the  poisonous  ma- 
terial may  cease.  The 
source  of  the  infection 
is  invariably  found  in 
the  decay  of  a  tooth  or 
the  root  of  a  tooth  pre- 
viously extracted.  Such 
a  tooth  should  be  treated 
or  extracted  without  de- 
lay, no  matter  in  what 
stage  the  infection  may 
be.  If  the  tooth  is  con- 
sidered by  the  dentist  to 
be  worth  saving,  its  cav- 
ity should  be  cleaned 
and  disinfected  so  that 
further  absorption  shall 
not  take  place.  The  fill- 
ing of  such  a  tooth  may 
be  postponed  until  the 
acute  symptoms  have 
subsided.  If  a  tooth  is 
too  far  gone  to  be  saved, 
it  should  be  immediately  extracted.  Many  dentists  object  to  the 
removal  of  a  tooth  if  an  abscess  is  present,  and  advise  the  patient 


Fig.  16.  —  Alveolar  Abscess  from  Decayed 
Lower  Teeth;  lanced  inside  and  outside  six 
weeks  previously.  Roots  of  teeth  not  removed. 
Swelling  due  to  fibrous  induration.  No  sinus 
and  no  pus,  as  far  as  can  be  made  out. 


46 


INFLAMMATIONS  OF  THE  HEAD 


to  wait    until   the  abscess  lias  been  cured.      This  is  bad   advice. 
It  would   be  just  as  logical  to  wait  for  a  cellulitis  of  an  arm  to 

subside  before  extract- 
ing the  splinter  in  the 
hand  which  caused  it. 
In  a  great  many  in- 
stances the  extraction  of 
a  decayed  tooth  or  of 
an  old  root  will  give 
the  ]>ns  formed  about  its 
deeper  portions  a  free 
opportunity  to  escape 
into  the  month,  so  that 
the  abscess  drained  in 
this  manner  will  rap- 
idly subside  in  a  few 
hours.  Even  if  suppu- 
ration has  extended  so 
far  from  the  tooth  that 
the  extraction  of  the 
latter  will  not  afford 
sufficient  drainage,  it 
should  still  be  insisted 
upon,  as  removal  of  the 
source  of  trouble  will 
hasten  the  recovery, 
will  relieve  the  patient 
at  once  of  a  consider- 
able amount  of  pain,  and  will  prevent  also  the  recurrence  of  the 
abscess  and  the  other  complications  spoken  of  above. 

If  further  drainage  is  necessary,  as  it  is  in  every  advanced 
case  of  alveolar  abscess,  the  incision  should  be  made  through  the 
gum  rather  than  through  the  cheek.  In  suppuration  of  the  lower 
jaw  the  drainage  through  the  mouth  is  an  attempt  to  cause  pus 
to  flow  up  hill,  but  it  will  in  many  cases  succeed  if  the  incision 
through  the  gum  is  a  wide  one  and  the  abscess  cavity  is  syringed 
out  once  or  twice  daily  with  diluted  peroxid  of  hydrogen  and  kept 
open  by  antiseptic  gauze.  A  day  or  two  will  prove  Avhether  or 
not  this  attempt  will  be  successful.     If  not,  an  external  incision 


Fig.  17. — Tumor  Following  Alveolar  Abscess, 
thought  to  be  Sarcoma.  Tooth  ulcerated 
three  and  one-half  months  previously. 


ACUTE   CONJUNCTIVITIS  47 

should  also  be  made.  This  need  not  be  a  very  Long  one,  since  the 
internal  incision  should  still  be  kept  open,  and  will  provide;  for 
the  escape  of  most  of  the  pus.  An  external  incision  is  to  be 
avoided,  not  only  on  account  of  the  annoyance  to  the  patient  of 
a  bandage  around  the  head,  but  because  the  resulting  scar  is  some- 
times attached  to  the  jaw  bone,  and  thus  forms  a  prominent  dim- 
ple. This  need  not  be  a  permanent  disfigurement,  however,  for 
such  a  dimple  may  be  removed  by  excision  of  the  scar,  dissection 
of  the  skin  for  a  half  inch  in  every  direction,  and  suture  of 
the  skin.  It  is  better  not  to  perform  this  plastic  operation  till 
some  months  have  passed,  lest  viable  germs  in  the  tissues  may 
be  roused  into  activity,  and  suppuration  defeat  the  end  of  the 
operation. 

A  sequestrum  of  the  jaw,  due  to  delayed  drainage,  will  usually 
loosen  in  a  few  weeks,  so  that  it  may  be  extracted  through  an  en- 
larged sinus,  either  within  the  mouth  or  externally.  Sometimes 
it  is  necessary  to  chisel  away  some  newly  formed  bone  to  make 
a  larger  exit.  In  most  cases,  if  a  general  anesthetic  is  given,  so 
that  the  surgeon  does  not  feel  the  need  of  haste,  he  can  twist  the 
sequestrum  back  and  forth,  and  perhaps  break  off  some  portions 
of  it,  until  it  can  be  withdrawn  without  chiseling  away  any  living 
bone. 

INFLAMMATIONS   OF   THE   EYE 

There  are  some  inflammations  of  the  conjunctiva  which  will 
be  here  discussed  because  of  their  frequency  and  importance,  and 
because  they  are  amenable  to  local  treatment. 

Acute  Conjunctivitis,  or  Simple  Catarrh. — Acute  in- 
flammation of  the  conjunctiva  may  be  divided,  for  practical  pur- 
poses, into  the  cases  which  are  due  to  the  gonococcus,  and  into  those 
which  are  not  thus  caused.  The  latter  cases  are  sometimes  called 
simple  or  catarrhal  or  muco-purulent  conjunctivitis. 

The  usual  signs  of  a  mild  catarrh  are  present.  The  secretion 
is  increased,  the  blood-vessels  are  injected,  there  is  a  little  swell- 
ing of  the  conjunctiva.  There  is  a  sense  of  heat  and  heaviness  in 
the  eye.  In  cases  which  develop  spontaneously  both  eyes  are 
affected  at  the  same  time  or  one  soon  after  the  other. 

A  number  of  micro-organisms  have  been  isolated  from  eyes 
in  such  a  mild  state  of  inflammation,  and  it  has  been  demon- 


48  INFLAMMATIONS  OF  THE   HEAD 

strated  thai  catarrhal  conjunctivitis  may  occur  in  epidemic  form. 
One  eve  may  l>e  involved  alone  as  the  result  of  traumatism. 

The  inflammation  in  catarrhal  conjunctivitis  may  go  on  until 

small  ulcers  are  formed,  hut  this  is  the  exception  rather  than  the 
rule,  and  the  outcome  is  complete  recovery  in  almost  all  cases. 

Trkatmkxt. — Tt  is  well  to  remember  that  most  cases  of  ca- 
tarrhal  conjunctivitis  are  distinctly  contagious,  and  the  infection 
may  be  transferred  from  one  eye  to  the  other,  or  from  one  person 
to  another.  Anything,  therefore,  which  comes  in  contact  with  the 
affected  eye  should  be  immediately  sterilized  or  destroyed. 

In  serious  cases  the  patient  should  he  kept  in  a  dark  room,  and 
several  pads  of  gauze,  four  or  five  layers  thick,  should  he  kept  on 
a  lump  of  ice  by  the  bedside  and  placed  by  the  patient  upon  his 
closed  eye.  Every  few  minutes,  as  they  become  warm,  they  should 
be  changed.  Several  times  a  day  the  eye  should  be  irrigated  with 
a  three  per  cent  solution  of  boracic  acid.  When  the  irritation  is 
less  intense,  an  application  of  a  twenty  per  cent  solution  of  argyrol, 
or  a  one  per  cent  solution  of  nitrate  of  silver,  should  be  applied 
by  the  surgeon  to  the  everted  lids,  and  almost  immediately  neu- 
tralized by  a  saline  solution.  Or  the  patient  may  be  given  a  solu- 
tion of  sulphate  of  zinc,  two  grains  to  the  ounce,  a  few  drops  of 
which  he  should  instill  into  the  affected  eye  once  or  twice  daily. 
The  edges  of  the  lids  should  be  smeared  at  night  with  a  simple 
ointment,  so  that  they  may  not  adhere  and  prevent  the  escape  of 
secretion. 

Purulent  Conjunctivitis. — Infection  of  the  conjunctiva 
with  the  gonococcus  is  a  serious  affection,  since  it  often  produces 
extensive  corneal  ulcers,  which  may  perforate  and  allow  the  iris 
to  prolapse,  and  which  in  any  event  are  likely  to  heal  with  opacity. 

The  disease  occurs  generally  in  new  born  infants,  or  in  adults. 
If  the  child's  eyes  are  infected  during  birth,  the  inflammation  ap- 
pears from  the  second  to  the  sixth  day.  If  it  appears  later  than 
this,  it  is  due  to  postnatal  infection.  In  both  infants  and  adults 
the  inflammation  is  due  to  contamination  of  the  eye  by  the  fingers, 
or  some  object  which  has  been  in  contact  with  a  discharge  contain- 
ing gonococci. 

In  the  first  day  or  two  the  patient  notices  pain  in  the  eyelids 
and  eyeballs,  and  sensitiveness  to  light.  There  are  fever  and 
swelling  of  the  lymph  glands  in  front  of  the  ears.     Later  the  dis- 


GRANULAR  LIDS  OR  GRANULAR  CONJUNCTIVITIS  49 

charge  from  the  eyes  becomes  purulent,  and  the  swelling  of  the 
lids  is  so  great  that  they  overlap  or  are  everted.  Ulcers  of  the 
cornea  develop.  The  disease  lasts  in  moderate  cases  from  four 
to  six  weeks. 

Treatment. — Prophylactic  treatment  is  most  important  for 
infants  and  for  adults  as  well.  The  eyes  of  every  child  after 
birth  should  be  carefully  washed  with  sterile  water  or  boracic 
acid  solution,  and  if  there  is  the  slightest  possibility  of  contagion 
from  the  mother,  a  few  drops  of  a  one  per  cent  solution  of  nitrate 
of  silver  should  be  instilled  into  each  eye.  Most  cases  in  adults 
are  due  to  autoinfection,  and  therefore  every  physician  caring  for 
a  patient  with  gonorrhea  should  explain  to  him  the  risk  of  infect- 
ing his  eyes,  and  give  him  directions  in  regard  to  the  use  of  towels, 
cleanliness  of  his  hands,  etc. 

The  patient  with  purulent  conjunctivitis  should  remain  in  bed 
in  a  darkened  room.  Ice  compresses  should  be  kept  on  the  eyes 
at  least  one-half  of  the  time,  and  the  eyes  should  be  frequently 
irrigated  with  a  solution  of  permanganate  of  potash  (1:  10,000). 
The  free  use  of  small  doses  of  calomel  will  do  much  to  decrease 
the  swelling  and  lessen  the  risk  of  corneal  ulcers.  The  edges  of 
the  lids  should  be  smeared  with  boric  acid  ointment  to  prevent 
their  adhering.  After  the  first  few  days  a  three  or  four  per  cent 
solution  of  nitrate  of  silver  may  be  applied  by  the  surgeon  to  the 
everted  lids  and  neutralized  with  a  saline  solution.  This  treat- 
ment may  be  repeated  once  a  day,  or  once  every  second  day.  The 
patient  should  be  careful  not  to  infect  the  sound  eye,  and  should 
sleep  with  this  eye  uppermost,  so  that  no  secretion  may  trickle  into 
it.  At  the  first  sign  of  redness,  the  sound  eye  should  be  treated 
with  a  two  per  cent  solution  of  nitrate  of  silver. 

Stye.— (See  p.  37.) 

Granular  Lids  or  Granular  Conjunctivitis. — Eepeated 
irritation  of  the  eye  will  often  result  in  an  injection  of  the  blood- 
vessels of  the  eyelids,  and  a  dry  and  rough,  almost  sandy  feeling. 
Badly  nourished  individuals,  such  as  anemic  children  and  overfed 
adults  with  a  uric  acid  diathesis,  are  especially  liable  to  this  con- 
dition. In  many  persons  it  is  brought  about  in  a  mild  degree  by 
the  excessive  use  of  the  eyes,  or  by  the  lack  of  suitable  glasses,  or 
by  exposure  to  wind  or  dust. 

An  inspection  of  the  lids,  and  especially  the  upper  one,  will 


50  INFLAMMATIONS   OF   THE   HEAD 

show  that  the  normal  smooth  pinkish  lining  presents  an  angry 
appearance,  due  to  the  injection  of  the  blood-vessels,  and  thai  by 
oblique  illumination  the  surface  is  irregular,  suggesting  granu- 
lations. 

In  mild  cases  the  removal  of  the  cause  and  the  instillation  into 
the  eye  of  a  few  drops  of  concentrated  boric  acid  solution  twice 
daily  will  speedily  effect  a  cure.  If  lithiasis  exists,  urinary  dilu- 
ents should  be  given  with  several  glasses  of  water  daily  in  addition 
to  the  local  treatment.  If  these  simple  measures  fail,  the  con- 
junctiva of  the  lids  should  be  wiped  occasionally  with  a  crystal 
of  copper  sulphate. 

Trachoma. —  The  disease  is  marked  by  the  formation  of 
whitish  or  pinkish  bodies  in  the  conjunctiva,  especially  of  the 
upper  lid.  It  is  generally  considered  to  be  contagious,  although 
it  is  much  more  common  among  anemic  children,  and  those  who 
are  crowded  together  in  rather  unhealthful  surroundings. 

The  affected  eye,  in  addition  to  the  granules  above  mentioned, 
usually  shows  the  signs  of  catarrhal  inflammation,  and  in  a  later 
stage  there  are  dilated  blood-vessels  and  the  formation  of  fibrous 
tissue  over  the  cornea  as  well  as  over  other  portions  of  the  eye. 
In  this  manner  the  vision  may  be  completely  lost. 

Treatment. — One  of  the  best  methods  of  treatment  is  the 
application  of  a  smooth  crystal  of  sulphate  of  copper  to  the  af- 
fected conjunctiva.  For  fifteen  minutes  thereafter,  cold  wet  appli- 
cations should  be  made  to  the  eye.  In  severer  cases,  the  granula- 
tions are  scraped  or  cut  away  or  squeezed  out.  For  the  details  of 
such  treatment  the  reader  is  referred  to  special  text-books  upon 
the  eye. 

Any  treatment  to  be  successful  must  be  continued  for  months, 
until  the  tendency  to  form  new  granulations  has  been  entirely 
overcome.  As  the  presence  of  this  disease  keeps  a  child  out  of 
school,  and  for  that  reason,  even  without  a  permanent  impairment 
of  sight,  seriously  handicaps  his  future,  those  in  charge  of  public 
institutions  containing  children  should  spare  no  pains  to  prevent 
this  disease  and  to  eradicate  it  when  it  occurs. 

Ingrowing  Lashes  or  Trichiasis. — It  sometimes  happens 
that  the  eyelashes,  instead  of  growing  in  the  normal  direction, 
curve  inward  and  thus  become  a  constant  source  of  irritation  to 
the  eyeball.    This  is  one  of  the  complications  of  granular  conjunc- 


OTITIS  MEDIA  51 

tivitis.  A  wedge-shaped  strip  may  be  cut  from  the  outer  surface 
of  the  eyelid  and  the  wound  sutured.  The  wedge  must,  of  course, 
include  the  whole  thickness  of  the  cartilage  of  the  eyelid  in  order 
to  secure  a  permanent  eversion  of  the  lashes.  The  lines  of  the 
incisions  should  be  parallel  to  the  edge  of  the  lid,  and  the  one 
nearest  the  edge  should  be  distant  from  it  an  eighth  of  an  inch,  so 
as  to  avoid  the  roots  of  the  eyelashes.  For  the  details  of  this 
operation  the  reader  is  referred  to  text-books  upon  the  eye.  Single 
lashes  may  be  extracted  by  means  of  smooth  forceps — that  is,  for- 
ceps whose  points  are  free  from  ridges  or  teeth,  for  the  latter 
would  be  apt  to  break  the  hairs.  This  is  naturally  a  purely  palli- 
ative procedure,  as  the  lash  will  soon  grow  in  exactly  as  before ; 
but  the  relief  occasioned  by  it  is  immediate  and  so  gratifying  that 
the  patient  will  gladly  return  month  after  month  to  have  the 
offending  hairs  again  extracted. 

If  only  two  or  three  hairs  forming  a  single  group  are  turned 
inward,  the  simplest  method  of  cure  is  the  removal  of  a  small  sec- 
tion of  the  edge  of  the  lid  containing  these  hairs,  and  the  suture 
of  the  gap  thus  caused. 

INFLAMMATION   OF   THE   EAR 

Otitis  Media. — This  is  a  common  disease  of  childhood,  usu- 
ally following  a  cold  in  the  head.  The  prominent  symptom  is  ear- 
ache. Every  physician  ought  to  be  able  to  recognize  the  bulging 
outward  of  the  membranum  tympani  and  to  relieve  the  pressure 
by  incision  of  the  membrane  at  the  most  favorable  situation — viz., 
the  inferior  and  posterior  portion.  The  introduction  of  warm 
olive  oil  into  the  external  meatus  will  sometimes  relieve  pain,  and 
the  application  of  external  heat  may  also  be  tried ;  but  the  pain  of 
a  severe  earache,  unless  relieved  by  puncture  of  the  membrane, 
usually  demands  the  internal  administration  of  morphine.  The 
membrane  usually  ruptures  spontaneously  in  the  course  of  a  day 
or  two.  Pain  is  then  relieved,  and  a  muco-purulent  discharge  be- 
gins and  continues  for  a  time.  After  it  ceases  the  membrane  soon 
heals  over.  While  the  discharge  continues,  the  treatment  consists 
in  cleanliness.  The  ear  should  be  syringed  gently  once  or  twice  a 
day  with  warm  normal  salt  solution,  and  wiped  dry  with  absorbent 

cotton. 

6 


A9 


INFLAMMATIONS   OF  T1IK   JIKA1) 


Unfortunately,  this  simple  termination  is  not  the  only  one 
which  is  possible,  for  inflammation  of  the  middle  ear  may  extend 
to  the  mastoid  cells,  and  result  in  abscess  within  the  cavity  of  the 
mastoid  bone.  If  prompt  drainage  is  qo1  instituted,  the  suppura- 
tion may  extend  into  the  lateral  sinuses  and  to  the  membranes  of 
the  brain,  causing  the  death  of  the  patient.  Hence  the  necessity 
of  early  recognition  of  the  disease  and  prompt  treatment  before 
these  serious  complications  have  arisen. 

The  external  ear  should  be  cleansed  by  washing  it  with  small 
cotton  swabs  wet  with  a  warm  antiseptic  solution,  and  the  mem- 
brane anesthetized  by  the  instil- 
lation of  a  few  drops  of  a  ten 
per  cent  solution  of  coca  in.  An 
ear  speculum  should  then  be 
introduced,  the  membrane  in- 
spected by  reflected  light  or  a 
headlight,  and  incised  in  its 
lower  and  posterior  portion  by 
means  of  a  long  slender  scalpel 
bent  in  the  handle  at  an  angle. 


Nl 

. 

Fig.  18. — Sketch  of  the  Normal  Right      Fig.  19. — Angular  Knife  for  Incision 
Tympanic  Membrane.     Showing  the  of  the  Tympanic  Membrane. 

correct  site  for  incision. 


Figure  18  shows  the  normal  membrane,  and  the  correct  size  of  an 
incision,  which  should  be  of  sufficient  length  to  permit  the  escape 
of  the  pus  and  mucus.  Figure  19  shows  a  good  knife  for  making 
the  incision. 

When  the  incision  has  been  made  through  the  bulging  mem- 


SUPPURATION   IN   THE   FRONTAL   SINUSES  53 

brane,  a  few  drops  of  pus  and  mucus  and  often  a  little  blood  will 
escape.  Irrigation  is  not  necessary,  but  the  auditory  canal  should 
be  sponged  clean  with  cotton-tipped  probes  dipped  in  a  warm 
antiseptic  solution.  In  the  case  of  a  nervous  or  restless  child,  it 
is  best  to  perform  this  operation  in  general  anesthesia.  The  inci- 
sion can  then  be  more  accurately  made. 

The  after  treatment  consists  in  cleanliness.  The  canal  should 
be  wiped  or  washed  clean,  and  the  inner  ear  protected  from  tem- 
perature changes  by  a  small  cone  of  dry  absorbent  cotton  intro- 
duced after  each  cleansing  and  as  often  as  the  previous  cone  be- 
comes moist. 

Boils. — A  description  of  boils  of  the  external  auditory  meatus 
is  given  on  page  37. 

INFLAMMATIONS   OF   THE   NOSE 

Acute  rhinitis  may  be  accompanied  by  a  troublesome  herpes 
of  the  lower  portion  of  the  anterior  nares  and  the  upper  lip.  The 
application  of  menthol  in  albolene  (gr.  x— Sj)  gives  some  relief. 
The  surrounding  skin  should  be  smeared  with  carbolic  salve  to  pre- 
vent the  spread  of  the  process. 

Chronic  Rhinitis. — The  usual  outcome  of  chronic  rhinitis  is 
hypertrophy  or  atrophy  of  the  mucous  membrane  of  the  nasal  pas- 
sages. 

Hypertrophy  of  the  inferior  turbinate  bone  in  many  cases  is 
best  cured  by  removal  of  the  major  portion  of  this  bone.  This  is 
a  minor  surgical  operation,  and  one  whose  technical  difficulties 
are  not  great,  but  the  decision  as  to  the  necessity  for  its  per- 
formance and  as  to  the  manner  of  its  removal  demands  a  thorough 
knowledge  of  the  pathology  of  the  nose,  which  the  reader  will  find 
fully  given  in  books  upon  that  special  topic. 

There  are,  however,  two  complications  of  rhinitis  which  may 
require  immediate  treatment,  and  which  are  therefore  here  de- 
scribed. 

Suppuration  in  the  Frontal  Sinuses. — In  many  cases  of 
influenza  and  other  forms  of  rbii  litis  the  inflammation  and  swell- 
ing of  the  mucous  membrane  extends  to  the  accessory  sinuses  of 
the  nose,  the  most  important  of  which  are  the  frontal  sinuses  and 
the  antrum  of  Highmore.     Such  extension  prolongs  the  attack  and 


54  INFLAMMATIONS   OF  THE   HEAD 

increases  the  discharge,  but  usually  subsides  in  a  few  days.  In 
addition  to  the  general  symptoms  of  infection  there  are  usually 
pain  and  tenderness  throughout  the  area  occupied  by  the  sinus, 
so  that  the  diagnosis  is  not  difficult  to  make  if  its  possibility  is 
borne  in  mind. 

In  certain  cases  the  inflammation  becomes  purulent  in  char- 
acter. Even  then  the  patient  is  ordinarily  relieved  by  a  discharge 
of  pus  and  mucus  through  the  natural  opening.  Should  relief  be 
not  afforded  in  this  manner,  the  sinus  may  be  drained  through 
l  he  nose  after  removal  of  the  middle  turbinate.  This  requires 
special  teclmic.  If  the  symptoms  are  severe,  and  especially  if 
there  is  reason  to  feel  that  extension  to  the  brain  is  threatened, 
an  incision  should  be  made  through  the  eyebrow  and  the  sinus 
drained  directly  by  chiseling  through  the  bone,  either  above  or 
below  the  margin  of  the  orbit.  This  operation  is  extremely  sim- 
ple, if  one  has  at  hand  a  small  sharp  chisel,  and  in  certain  cases 
it  saves  a  person's  life.  The  wound  should  be  drained  until  the 
suppuration  ceases.     There  is  only  a  slight  permanent  scar. 

Suppuration  in  the  Antrum  of  Highmore. — Like  sup- 
puration in  the  frontal  sinus,  this  follows  acute  coryza,  but  it  may 
also  be  secondary  to  diseases  of  the  teeth,  especially  of  the  canine 
tooth. 

The  symptoms  are  pain  and  fulness  in  the  roof  of  the  mouth, 
usually  with  intermittent  discharge  of  pus  from  the  nose.  This 
temporarily  relieves  the  symptoms. 

Transillumination  is  a  valuable  means  of  diagnosis.  A  small 
electric  lamp  held  in  the  closed  mouth  shines  through  the  affected 
side  with  much  less  power  than  through  the  normal. 

Treatment. — A  large,  curved  trocar  and  canula  should  be 
passed  through  the  septum  between  the  antrum  and  the  inferior 
meatus  of  the  nose.  Through  this  canula  the  pus  can  be  washed 
out.  This  washing  should  be  repeated  daily  with  warm  Dobell's 
solution.  A  smaller  canula  should  be  employed  for  the  subsequent 
treatment,  so  that  it  can  be  passed  through  the  opening  first  made 
without  difficulty. 

More  direct  drainage  is  obtained  by  chiseling  away  a  part 
of  the  anterior  wall  of  the  antrum  through  an  incision  made  at 
the  reflexion  of  the  mucous  membrane  from  the  upper  jaw  to  the 
cheek.     This  incision  should  extend  from  the  canine  tooth  to  the 


PERITONSILLAR  ABSCESS  .r)5 

first  molar.  If  the  canine  or  one  of  the  bicuspid  teeth  is  already 
diseased,  the  opening  may  be  made  through  its  socket.  The  sinus 
should  be  irrigated  daily  for  a  week  or  two  until  the  suppuration 
subsides. 

Boils.— (See  p.  36.) 

INFLAMMATIONS   OF   THE   MOUTH   AND   THROAT 

Stomatitis  and  Gingivitis. — The  occurrence  of  these  low 
degrees  of  inflammation  in  the  mouth  usually  indicates  a  low 
degree  of  vitality,  or  in  certain  cases  that  the  vitality  has  been 
reduced  by  poisons — for  example,  mercury. 

Treatment. — The  general  condition  should  be  improved  by 
changes  in  diet  and  tonics.  If  there  is  a  local  cause  for  the  trouble, 
such  as  decayed  or  neglected  teeth,  this  should  be  attended  to. 
The  patient  should  be  given  a  stimulating  mouth  wash,  such  as 
a  solution  of  permanganate  of  potash,  one  grain  to  the  ounce ;  or 
a  mixture  of  tincture  of  myrrh,  one  part  in  twenty  of  water.  The 
inflamed  gums  may  be  painted  with  the  tincture  of  myrrh. 

Such  inflammations,  even  when  severe,  rarely  lead  to  suppu- 
ration, and  require  no  operative  treatment. 

Alveolar  Abscess. — (See  p.  39.) 

Peritonsillar  Abscess. — Certain  cases  of  acute  tonsilitis  are 
followed  by  the  formation  of  an  abscess,  either  within  the  tonsil 
or,  as  is  more  common,  in  the  tissues  around  it.  In  the  latter 
case  the  most  common  situation  is  above  the  tonsil. 

It  is  of  importance  to  recognize  early  the  collection  of  pus, 
either  within  or  outside  of  the  tonsil,  since  its  early  evacuation 
before  a  large  abscess  cavity  has  formed  greatly  shortens  the 
course  of  the  disease.  Sometimes  the  patient  first  recognizes  the 
extension  of  the  swelling  outside  of  the  tonsil.  Inspection  will 
show  the  mucous  membrane  over  the  abscess  to  be  of  a  dusky  red 
hue,  and  the  palpating  finger  will  reveal  an  area  of  induration  with 
fluctuation  in  its  center.  Under  such  circumstances  an  incision 
should  be  promptly  made.     Nothing  but  pain  is  gained  by  delay. 

Treatment. — As  soon  as  the  abscess  is  recognized  it  should 
be  evacuated  through  a  suitable  incision.  The  mucous  membrane 
is  readily  cocainized  by  the  application  to  it  for  five  minutes  of  a 
swab  wet  with  a  ten  per  cent  solution  of  cocain.     If  there  is  any 


56  INFLAMMATIONS   OF  THE    HEAD 

doubt  as  to  the  situation  <>t'  the  pus,  aspiration  should  be  per- 
formed. A  hypodermic  syringe  is  sufficiently  large  for  the  pur- 
pose, provided  a  needle  of  good  size  be  employed.  The  incision 
should  be  made  in  the  center  of  the  abscess,  the  stroke  being  from 
without  inward  in  order  to  avoid  wounding  any  deep  vessel. 
When  the  abscess  cavity  has  been  opened,  the  incision  may  be 
enlarged  with  knife  or  scissors  in  whatever  direction  will  give  the 
best  drainage.  If  a  drain  is  to  be  employed,  it  is  a  good  plan  to 
cut  out  a  small  triangular  portion  of  the  mucous  membrane  to 
insure  an  opening  sufficiently  Large  to  permit  the  reinsertion  of 
the  gauze.  It  is  a  good  plan  to  syringe  the  cavity  once  or  twice  a 
day  with  a  mixture  of  one  part  of  peroxid  of  hydrogen  to  eight 
of  water. 

Retropharyngeal  Abscess. — Abscess  between  the  posterior 
wall  of  the  pharynx  and  the  cervical  vertebrae  is  usually  seen  in 
badly  nourished  children,  and  is  secondary  to  infective  processes 
in  the  nose  or  throat  or  ear  in  the  large  majority  of  cases.  The 
immediate  symptoms  of  an  abscess  in  this  situation  r.re  pain  and 
difficulty  in  swallowing  and  in  breathing.  The  general  symptoms 
of  unrelieved  suppuration,  high  pulse  and  temperature,  anorexia, 
etc.,  are  well  marked. 

The  posterior  wall  of  the  pharynx  bulges  forward  toward  the 
soft  palate,  and  may  often  be  felt  to  fluctuate  when  palpated.  As 
a  further  confirmation  of  the  diagnosis,  and  as  a  guide  to  the  inci- 
sion, the  boggy  swelling  should  be  aspirated  with  a  needle  of  good 
size.  Pus  having  been  located,  should  be  at  once  evacuated.  It 
is  exhausting  to  the  patient  to  allow  it  to  remain,  and  there  is 
in  this  case  the  added  danger  that  the  abscess  may  rupture  dur- 
ing sleep,  and  the  patient  be  drowned  in  the  pus  which  pours  into 
his  throat. 

Treatment.- — When  the  pus  has  been  recognized,  it  should  be 
evacuated  through  an  incision  made  in  the  median  line  of  the 
pharynx  as  low  down  as  possible.  A  child  should  be  wrapped 
and  pinned  in  a  sheet  so  that  his  arms  can  be  easily  controlled, 
and  a  good  mouth-gag  placed  in  position.  A  few  inhalations  of 
chloroform  do  not  materially  add  to  the  risk  of  operation,  and 
spare  the  feelings  of  patient,  mother,  and  doctor.  Various  posi- 
tions for  the  patient  have  been  recommended,  all  of  them  with 
the  idea  of  giving  the  operator  a  good  view  of  the  throat  and  pre- 


ECZEMA  57 

venting  the  evacuated  pus  from  flowing  down  into  the  larynx.  A 
horizontal  lateral  position  is  perhaps  as  good  as  any.  The  finger 
should  guide  the  knife,  all  but  the  point  of  which  should  be  pro- 
tected by  wrapping  it  with  adhesive  plaster.  The  most  prominent 
point  in  the  swelling  should  he  punctured,  and  the  incision  quickly 
enlarged  either  upward  or  downward,  as  the  case  may  require. 
The  knife  is  then  withdrawn  and  the  body  of  the  child  somewhat 
elevated  and  turned  so  that  the  pus  may  flow  out  of  the  mouth. 
The  abscess  cavity  should  be  irrigated  with  saline  solution,  but 
not  drained.  By  palpation  the  operator  should  convince  himself 
that  a  sufficient  opening  has  been  made  to  assure  free  drainage. 
Hemorrhage  may  be  controlled  by  a  temporary  packing  of  the 
wound  with  gauze. 

The  after  treatment  consists  in  attention  to  the  general  health 
of  the  child  and  irrigation  of  the  cavity,  should  it  show  any  tend- 
ency to  close  and  allow  accumulation  of  pus.  Should  this  not  be 
the  case,  it  is  unnecessary  to  annoy  the  child  with  irrigation,  which, 
of  course,  has  to  be  carried  out  in  a  partially  inverted  position. 

It  has  been  recommended  to  open  a  retropharyngeal  abscess 
laterally  through  an  incision  made  in  front  of  the  sternomastoid 
muscle.  This  route  should  only  be  followed  in  case  the  pus  has 
already  burrowed  in  that  direction.  Otherwise  the  dissection  is 
difficult  and  not  without  risk,  and  the  drainage  is  not  always  satis- 
factory by  this  route. 

INFLAMMATIONS  OF  THE   SKIN 

Acute  suppurations  of  the  skin  are  described  on  page  32. 

Eczema. — Eczema  of  the  face  or  scalp  is  often  accompanied, 
especially  in  children,  by  abundant  secretion,  which  as  it  dries 
forms  crusts.  These  in  turn  increase  the  itching,  and  as  they  are 
torn  off,  raw  surfaces  result,  so  that  blood  mixes  with  the  serum 
in  the  formation  of  new  crusts.  It  is  not  surprising  under  the 
circumstances  that  the  skin  becomes  infected  and  local  cellulitis 
develops,  or  possibly  suppuration  in  the  regional  lymph  nodes 
(see  Fig.  77,  p.  130).  The  risk  of  infection  is  greatest  when  the 
eczema  involves  the  scalp  of  a  young  child. 

Treatment. — In  order  to  avoid  the  complications  of  infection, 
the  scalp  should  be  saturated  with  sweet  oil  for  some  hours  to 


58  INFLAMMATIONS   OF  THE    HEAD 

soften  the  crusts.  These  should  then  be  removed  and  the  head 
gently  but  thoroughly  washed  with  hot  water  and  soap,  and  the 
hair  cut  short.  Compresses  saturated  with  such  a  lotion  as  four 
per  cent  aluminum  acetate,  or  one  half  per  cent  creolin,  should 
then  be  applied.  When  the  inflammation  has  somewhat  subsided, 
Lassar's  paste  or  boraeic  acid  ointment  should  he  used.  It  is  gen- 
erally supposed  that  it  aggravates  an  eczema  to  wash  the  skin  with 
soap  and  water,  but  if  this  is  gently  done,  the  skin  thoroughly 
dried,  and  some  greasy  application  is  at  once  made  to  replace  the 
fat  extracted  by  the  soap,  the  benefits  of  cleanliness  are  obtained 
without  harmful  results. 

Whatever  the  remedy  chosen,  such  general  measures  as  tend  to 
improve  the  nutrition  of  the  child  should  he  attended  to,  and 
scratching  should  be  prevented,  even  though  the  hands  have  to 
be  tied. 

Ringworm. — Ringworm,  whether  of  the  non-hairy  skin, 
scalp,  or  bearded  face,  is  due  to  the  growth  in  the  skin  of  certain 
fungi.  The  disease  is  therefore  contagious,  and  may  be  trans- 
mitted by  contact  or  by  an  exchange  of  articles  of  clothing,  towels, 
etc.  The  patient  affected  is  usually  a  child  or  young  adult.  The 
tendency  of  the  infection  to  spread  equally  in  all  directions  gives 
the  lesion  a  more  or  less  circular  appearance,  and  if  the  skin 
affected  contains  few  hairs  the  center  of  the  area  may  have  re- 
sumed a  normal  appearance  while  the  growth  is  still  active  at  the 
periphery.  The  rate  of  growth  varies,  being  at  first  more  active, 
so  that  a  ring  an  inch  in  diameter  may  he  formed  in  two  weeks 
in  the  non-hairy  skin.  Later;  there  is  a  tendency  for  the  disease 
to  die  out,  so  that  the  ring  may  he  incomplete  or  exist  only  in 
spots.  If  the  ringworm  occurs  in  the  scalp  or  bearded  face,  the 
scaliness  observed  upon  the  non-hairy  skin  is  much  exaggerated, 
crusts  are  added,  and  there  is  incomplete  loss  of  the  hair  within 
the  affected  area. 

Treatment. — The  affected  area  should  be  washed  free  from 
scales  and  crusts  by  green  soap  and  water.  If  the  non-hairy  skin 
is  affected,  the  disease  can  he  speedily  cured  by  washing  the  part 
with  a  solution  of  bichlorid  of  mercury,  two  grains  to  the  ounce 
of  water.  Other  strong  antiseptic  solutions  are  equally  efficacious. 
If  the  hairy  skin  is  affected,  a  depilatory  should  be  applied  to  get 
rid  of  the  stumps  of  hair.     Stelwagon  recommends  a  mixture  of 


SYPHILIS  59 

three  drams  of  barium  sulphid  and  two  and  a  half  drams  each  of 
zinc  oxid  and  powdered  starch.  At  the  time  of  use,  this  is  rubbed 
to  a  paste  with  a  little  water  and  applied  for  five  to  ten  minutes 
and  then  washed  off.  Sulphur  ointment,  diluted  if  necessary, 
should  be  rubbed  into  the  area  every  day  or  two.  Another  plan  is 
to  paint  it  with  a  solution  of  chrysarobin  in  chloroform,  and  to 
cover  this  with  two  or  three  coats  of  collodion.  Many  other  anti- 
septics, both  in  salves  and  lotions,  have  been  employed  with  suc- 
cess. One  should  persist  in  treatment  until  every  trace  of  the 
disease  has  disappeared. 

Ulcers. — Simple  ulcers  of  the  face  occurring  in  marasmic  per- 
sons, especially  young  infants,  are  readily  healed  if  the  general 
condition  of  the  patient  can  be  improved.  Cleanliness  and  a  sim- 
ple dressing — for  example,  a  wet  dressing  of  creolin,  one  per  cent 
— are  the  only  local  treatment  needed.  The  question  of  syphilis 
ought  always  to  be  considered. 

Anthrax,  or  malignant  pustule,  is  found  on  the  hands  and 
arms  perhaps  more  frequently  than  on  the  face  and  neck.  It  is 
described  on  page  132,  where  a  clear  picture  of  an  early  pustule 
is  given. 

Noma. — This  is  a  localized  gangrene  of  the  face  and  mouth, 
usually  seen  in  a  person  exhausted  by  some  infectious  disease.  It 
begins  in  the  mucous  membrane  of  the  gums  or  cheeks.  The  tis- 
sues are  first  indurated,  and  then  become  gangrenous.  There  is 
no  fever.  The  process  leads  to  perforation  of  the  cheek,  loss  of 
the  teeth,  necrosis  of  the  jaw,  etc.,  and  usually  terminates  in  death 
within  a  wTeek  or  ten  days. 

CHRONIC   INFLAMMATIONS 

Syphilis. — The  primary  lesion  of  syphilis  is  occasionally 
found  in  the  lip  or  cheek  or  tongue.  The  unusual  site  of  the  lesion 
and  the  fact  that  it  may  be  found  here  in  the  pure-minded,  often 
lead  to  an  error  in  diagnosis.  Hence  the  exact  appearance  of  the 
indurated  sore  is  of  great  importance.  Infection  usually  takes 
place  through  a  visible  break  in  the  skin — a  cigarette  burn  in  one 
of  the  cases  figured  in  the  accompanying  illustrations — but  such 
a  break  will  be  obscured  by  the  primary  sore  in  a  few  days.  In 
a  week  or  two  the  induration  and  redness  become  marked. 


(ill 


INFLAMMATIONS    <>K  THE   HEAD 


Fig.  20. — Chancre  of  Lower  Lip  of  Nine  Days'  Dura- 
tion.    Patient  a  man  aged  thirty-six  years. 


Lf  the  lesion  is  on  the  lip  (Fig.  20),  its  dcvelopinenl  is  similar 
to  thai  of  a  chancre  of  the  penis.  There  is  the  same  elevated,  com- 
paratively painless 
swelling  with  shal- 
low ulceration,  but 
later  the  extenl  of 
the  deep  indura- 
tion usually  ex- 
ceeds thai  found  in 
an  unmixed  sore 
of  the  penis  ( Fig. 
21). 

When  the  pri- 
mary lesion  occurs 
in  still  thicker  skin 
(for  example,  that 
of  the  cheek),  this 
induration  and  the  subsequent  ulcer  are  still  larger  than  is  usu- 
ally the  ease  when  the  primary  sore  occurs  in  the  genitals.  In  a 
few  days  the  surface  is  covered  with  a  dry  scab  (Fig.  22)  if  the 
lesion  is  out  of  the  area  bathed  with  the  saliva.  The  regional 
lymphatic  glands  are  swollen,  but  are  not  very  tender.  A  few  days 
later  the  scab  falls  off, 
and  a  shallow  ulcer  is 
formed  (Fig.  23).  As 
healing  takes  place  the 
induration  subsides, 
the  ulcers  become 
filled  with  granula- 
tions, and  the  epithe- 
lium grows  over  it. 
The  only  permanent 
disfigurement  is  a 
small  scar  containing, 
perhaps,  a  little  pig- 
ment. This  is  insig- 
nificant when  compared  with  the  active  lesion,  so  that  in  this 
respect  the  patient  may  be  encouraged. 

The  persistence  of  the  lesion  for  a  week  or  more  in  a  healthy 


Fig.  21. — Chancre  of  Lower  Lip  of  Three  Weeks' 
Duration.  Patient  a  man  aged  twenty-four 
years. 


SYPHILIS  61 


patient,  arid  the  Large  amount  of  induration  without  suppuration, 
serve  to  distinguish  the  primary  sore  of  syphilis  from  a  simple 
ulcer.  The  possible  youth  of  the  patient,  and  the  disappearance 
of  induration  either  with  or  without  the  use  of  antisyphilitic 
remedies,  serve  to  distinguish  it  from  cancer.     Cancer  is  the  more 


Fig.  22. — Chancre  of  Cheek,  Developing  in  Burn  from  Cigarette.     Duration  of 
lesion  2  months. — Patient  aged  19  years. 

unlikely  if  the  lesion  is  in  the  skin  of  the  face,  away  from  the 
mucocutaneous  junction  of  the  lip. 

Treatment.— Local  treatment,  while  not  essential,  relieves 
the  feelings  of  the  patient.  The  sore  should  be  covered  with  a 
collodion  dressing,  or  with  simple  ointment  and  a  small  patch  of 
muslin.  Mercuric  ointment,  on  account  of  its  suggestive  color, 
should  not  be  employed — at  least  by  day.  Internal  treatment  is 
all  important.     A  tablet  of  ^  of  a  grain  of  mercuric  protoiodid 


62 


INFLAMMATIONS  OF  THE  HEAD 


should  be  taken  after  each  meal,  or  ^  of  a  grain  of  mercuric  bin- 
iodid  with  10  grains  of  potassium  iodid,  well  diluted  in  water. 
Some  physicians  prefer  treatment  by  injection — e.  g.,  £  grain  of 
bichlorid  of  mercury  in  water  three  times  a  week,  or  5  to  8  drops 
of  a  ten  per  cent  emulsion  of  the  salicylate  of  mercury  in  albolene, 
once  a  week. 

Secondary    Lesions. — Mucous    patches    which    develop    in    the 
mouth  and  throat  (luring  the  secondary  stage  of  syphilis  in  some 


Fig.  23. — Chancre  of  Cheek  from  a  Bite.     The  ulcer  is  granulating. 

cases  make  the  patient  very  uncomfortable,  and  may  lead  to  sup- 
puration in  the  cervical  lymph  glands.  Gargles  and  sprays  of  mild 
antiseptics  give  some  relief,  but  the  chief  treatment  consists  in  the 
regular  administration  of  mercury  and  potassium  iodid.  The  sec- 
ondary eruption  on  the  skin  of  the  face,  and  particularly  of  the 
forehead,  annoys  the  patient  by  calling  attention  to  his  disease. 


TUBERCULOSIS 


63 


Mercuric  ointment  rubbed  into  the  individual  patches  at  night,  and 
wiped  off  with  a  dry  cloth  in  the  morning,  is  thought  to  hasten  the 
disappearance    of    these    lesions. 
Occasionally  a  well-developed  le- 
sion may  be  mistaken  for  a  new 
growth  (Fig.  24). 

Tertiary  Lesions. — Gumma 
may  develop  in  the  scalp  or  face, 
or   in    the    tongue   or   throat    or 


nose.  It  produces  a  deep-seated 
ulceration  which  heals  only  after 
the  permanent  destruction  of 
more  or  less  tissue.  There  is 
also  a  chronic  syphilitic  thicken- 
ing of  the  tongue  known  as  glos- 
sitis. The  whole  tongue  is  harder 
and  thicker  than  normal,  and  the 
mucous  membrane  in  particular 
is  furrowed  and  ridged  and  more 
shiny  than  normal.  Gumma  of 
the     scalp     often     involves     not 

only  the  skin,  but  the  periosteum  and  a  part  of  the  skull,  so 
that  there  may  be  necrosis  of  some  portions  of  the  outer  table 
of  the  skull.  The  separation  of  these  necrotic  portions  may  re- 
quire months.  Until  they  are  entirely  removed  complete  heal- 
ing is,  of  course,  impossible.  The  pus  which  undermines  the 
scalp  around  the  margins  of  the  sequestrum  may  require  incisions 
for  its  perfect  drainage.  These  late  lesions  of  syphilis,  with  the 
exception  of  the  glossitis,  usually  yield  readily  to  antisyphilitic 
treatment,  and  especially  to  the  administration  of  large  doses  of 
iodid  of  potash  up  to  a  dram  three  times  a  day.  Local  treatment 
is  unimportant.  There  is  no  excuse  for  keeping  a  patient's  face  or 
head  smeared  with  an  offensive  mercurial  ointment.  Mercury  can 
be  administered  more  pleasantly  and  more  accurately  by  mouth  or 
by  injections  or  inunctions.  Moreover,  under  suitable  moist  dress- 
ings, repair  takes  place  more  rapidly  than  when  mercuric  ointment 
is  used.    This  has  been  demonstrated  by  careful  measurements. 

Tuberculosis. — When  the  skin  is  the  seat  of  tuberculosis,  the 
lesion  is  spoken  of  as  lupus  vulgaris.     The  face  is  the  commonest 


Fig.  24. — Papilloma  of  Lip,  Found 
on  Microscopical  Examination 
to  be  Syphilitic.  Duration  of 
lesion  2  months.  Patient  aged  28 
years. 


CA  INFLAMMATIONS  OF  THE   ll I. Ah 

situation  for  this  disease,  especially  the  skin  of  the  nose  and 
cheeks.  A  number  of  reddish  areas  as  Large  as  a  pea,  perhaps, 
are  firsl  noticed  in  the  corium.  They  pale  on  pressure,  appear- 
ing yellowish  or  brownish.  As  the  disease  spreads,  the  tissue  first 
involved  may  ulcerate,  or  it  may  atrophy  and  hecome  cicatricial 
in  character.  As  the  course  of  the  affection  is  a  very  chronic  one, 
often  lasting  for  years,  the  appearances  of  the  lesion  vary  greatly 
and  a  variety  of  names  have  been  applied  to  indicate  these  differ- 
ent stages,  the  minute  description  of  which  will  be  found  in  any 
hook  upon  skin  diseases. 

Diagnosis. — Small  patches  of  lupus  may  he  confounded  with 
psoriasis,  but  inquiry  into  the  history  will  usually  serve  to  elimi- 
nate this  error.  The  lesions  of  psoriasis  are  persistent,  but  do  not 
involve  the  deeper  parts  of  the  skin,  do  not  extend  so  steadily, 
and  do  not  ulcerate.  Lupus  may  also  be  confounded  with  rodent 
ulcer.  In  this  disease  the  destructive  process  is  more  notice- 
able, while  the  reparative  is  less  so;  but  in  certain  instances 
a  microscopical  examination  may  be  necessary  to  differentiate 
the  two. 

Treatment. — The  diseased  tissue  may  be  removed  by  the 
curette,  or  by  caustics,  or  by  the  knife.  The  advance  of  the  growth 
has  sometimes  been  checked  by  linear  scarifications  about  one- 
eighth  of  an  inch  apart  and  crossing  each  other  at  right  angles. 
Ultra-violet  rays  and  the  x-ray  have  also  been  employed  with  good 
effect  in  many  cases.  These  last-named  agents  have  the  merit  of 
destroying  the  pathologic  tissue  with  far  less  resulting  scar  than 
chemical  caustics  or  the  knife. 

Tuberculosis  of  Nose  and  Mouth. — Tuberculosis  of  the  nose, 
mouth,  or  throat  is  of  rare  occurrence,  and  when  seen  is  usually 
secondary  to  tuberculosis  of  the  lung.  It  appears  in  two  forms, 
either  productive  or  ulcerative.  Both  processes  may  be  exhibited 
in  a  single  lesion.  It  may  be  difficult  to  differentiate  tuberculosis 
from  syphilis  until  a  microscopic  examination  of  an  excised  por- 
tion of  tissue  has  been  made,  or  the  patient  has  been  subjected  to 
treatment  by  mercury  and  iodine. 

Tuberculosis  of  the  mouth,  secondary  to  the  pulmonary  dis- 
ease, is  shown  in  the  accompanying  photograph  (Fig.  25). 

Treatment. — General  hygienic  treatment  is  important,  Local 
treatment,  such  as  the  application  of  caustics  or  the  partial  exci- 


GLANUKHS 


or. 


sion  of  tuberculous  tissue,  has  little  effect  upon  the  progress  of  the 
disease   while  in  this  situation  a  thorough  excision  is  impossible. 


Fig.  25. — Tuberculosis  of  the  Gum,  Secondary  to  Pulmonary  Tuberculosis. 

Actinomycosis. — This  should  be  borne  in  mind  as  one  of  the 
chronic  inflammatory  lesions  liable  to  occur  in  the  face,  and  espe- 
cially about  the  mouth  or  jaw.  It  begins  as  a  smooth  swelling, 
but  later  abscesses  form  and  discharge  pus  containing  yellowish 
granules.  These  may  be  recognized  by  the  naked  eye  or  under 
the  microscope  as  colonies  of  the  ray  fungus.  They  are  character- 
istic of  the  disease.  The  fungus  of  the  disease  in  man  is  similar 
to,  but  probably  not  identical  with,  that  of  the  disease  in  cattle 
called  "  lumpy  jaw." 

Treatment  consists  in  the  excision  of  diseased  tissue,  and  the 
administration  of  iodid  of  potash.    It  is  often  unsuccessful. 

Glanders. — This  disease  of  the  horse  and  other  animals,  when 
acquired  by  man,  usually  shows  its  first  growth  in  the  mouth, 
nose,  eyelids,  or  skin  of  the  face.  It  is  characterized  by  cellulitis, 
lymphadenitis,  and  inflammatory  nodules  which  break  down  into 
ulcers  with  undermined  borders.  Treatment  is  by  excision  and 
drainage.     In  rapidly  spreading  cases,  the  prognosis  is  grave. 


CHAPTEK    III 
TUMORS    AND    DEFORMITIES    OF    THE    HEAD 

CYSTIC   TUMORS 

Milium. — There  are  often  found  in  the  skin  of  the  face,  espe- 
cially near  the  eyes,  and  also  in  the  skin  of  the  external  genitals, 
male  and  female,  little  whitish  masses.  They  are  called  milia. 
They  are  made  up  of  closely  packed  epithelium  and  sebaceous 
material,  and  are  situated  just  beneath  the  epidermis.  A  milium 
is  distinguished  from  a  comedo,  or  blackhead,  by  the  fact  that 
I  here  is  no  obstructed  duct  in  the  epithelium  which  covers  it.  The 
nature  of  this  small  tumor  is  in  doubt. 

Milia  show  little  tendency  to  change  their  form.  As  they  are 
persistent,  their  removal  is  often  requested  by  the  patient.  The 
overlying  epidermis  should  be  split  with  the  point  of  a  small  sharp 
scalpel  and  the  contents  expressed.  This  method  is  less  painful 
and  more  successful  than  attempts  to  pick  out  the  mass  with  a 
needle. 

Comedo. — A  comedo,  or  blackhead,  is  the  lesion  produced 
by  the  blocking  of  a  sebaceous  duct.  The  dark  color  is  due  to  an 
admixture  of  dust  with  the  sebaceous  material.  They  are  most 
often  found  upon  the  face  and  neck. 

The  general  treatment  which  is  given  for  acne  (p.  33)  is  of 
service.  After  the  skin  has  been  softened  by  hot  bathing,  the 
individual  plug  may  be  loosened  by  a  needle  and  squeezed  out  by 
lateral  pressure.  This  pressure  should  in  all  cases  be  slight,  lest 
a  sluggish  inflammatory  process  be  converted  into  an  acute  one. 

Sebaceous  Cyst. — The  tumor  of  the  head  that  most  often 
attracts  notice  is  a  sebaceous  cyst.  These  cysts  occur  either  singly 
or  in  groups,  and  vary  in  size  from  the  smallest  nodule  which  can 
be  recognized  to  a  sac  two  inches  or  more  in  diameter.  They  are 
commonest  in  the  scalp,  but  also  occur  behind  the  ear,  in  the  eye- 
brow, or  fin  males)  in  the  skin  from  which  the  beard  springs. 
66 


SEBACEOUS  CYST 


67 


They  are  found  in  young  adults,  but  arc  most  common  in  those  of 
middle  age.  They  are  due  to  the  blocking  np  of  the  duct  of  a 
sebaceous  gland.  The  sebaceous  material  manufactured  by  the 
gland  collects  within  its  lumen  and  gradually  distends  its  cavity. 
As  the  distention  increases,  the  epithelial  lining  is  also  increased 
by  a  multiplication  of  its  cells.  Within  such  a  cyst  are  found  the 
cast-off  epithelial  cells  in  a  state  of  fatty  degeneration.  The  mate- 
rial contained  in  a  small  cyst  is  semisolid  and  pasty,  while  that 
contained  in  a  large  one  is  usually  more  fluid.  The  tumor  grows 
rapidly  at  times,  but  often  has  long  dormant  periods  during  which 
it  seems  not  to  grow  at  all. 

Diagnosis. — The  cyst  at  first  grows  within  the  skin,  and  can- 
not be  moved  independently  of  it.  As  it  increases  in  size,  it 
spreads  in  the  areolar 
tissue  beneath  the 
skin.  I.t  follows, 
therefore,  that  in  the 
case  of  a  large,  non- 
inflamed  cyst,  the  over- 
lying skin  is  movable 
upon  it  at  all  points 
excepting  at  the  cen- 
ter. This  single  fact 
will  usually  serve  to 
differentiate  a  sebace- 
ous cyst  from  a  wholly 
subcutaneous  tumor 
— for  example,  a  li- 
poma. 

If  left  to  itself,  a 
sebaceous  cyst  may 
attain  a  considerable 
size,  possibly  having 
a  diameter  of  two 
inches,  if  it  is  situated 
in  the  scalp.  The  usual  fate  of  a  sebaceous  cyst  situated  in  the 
face  is  to  undergo  inflammatory  changes  (Fig.  26),  possibly  with 
rupture  and  discharge  of  its  contents.  Such  a  discharge  is,  how- 
ever, but  temporary,  as  the  sac  generally  refills  in  a  short  time. 


Fig.  26. — Sebaceous  Ctst  of  Forehead,  Moder- 
ately Inflamed,  and  About  to  Rupture. 


IIS 


Ti  MORS    \\1>   DEFORMITIES  OF  THE  HEAD 


I  beatment. — Treatment  of  a  sebaceous  cysl  is  operative.  To 
guard  againsl  its  recurrence,  one  should  remove  the  whole  sac.  An 
operation   to  accomplish  this  is  readily  performed   under  cocain, 

unless  the  patient  is 
more  than  usually 
sensitive. 

In  the  case  of 
a  sebaceous  cyst  of 
i  lie  scalp,  one  should 
proceed  as  follows: 
First  shave  and 
cleanse  an  area  of 
I  lie  seal])  a  little 
larger  than  the 
tumor  (Fig.  27). 
While  shaving  adds 
to  the  convenience 
of  the  operator,  it 
not  absolutely  nec- 
essary, and  primary 
union  can  usually 
be  obtained  without 
it.  In  certain  cases, 
therefore,  it  may  be 
better  not  to  sacri- 
fice any  of  the  hair. 
The  rest  of  the 
Lead  outside  of  the  field  of  operation  should  be  covered  with 
towels  wrung  out  of  bichlorid  solution,  1 :  1,000.  A  few  drops 
of  one  per  cent  cocain  solution  are  next  injected  along  the  line 
of  incision.  This  weak  solution  is  desirable  in  these  cases,  since 
cocain  injected  into  the  head  appears  to  have  a  more  pronounced 
loxic  effect  than  when  used  in  other  portions  of  the  body.  The 
writer  has  known  the  injection  of  a  few  drops  of  a  four  per  cent 
solution  of  cocain  into  the  median  line  of  the  scalp  to  produce  such 
a  marked  reaction  that  artificial  respiration  was  twice  necessary 
before  its  effect  passed  off. 

A  straight  incision  should  be  made  directly  across  the  center 
of  (he  tumor,  from  one  edge  to  the  other,  extending  down  to  the 


Fig.  27. 


-Operation  for  Sebaceous  Cyst  of  Scalp. 
Skin  prepared. 


SEBACEOUS   CYST 


GO 


sac  without  entering  it.  If  the  correct  tissue-plane  is  reached,  it 
is  usually  possible  to  sweep  around  (lie  entire  sac  with  the  bandle 
of  the  scalpel,  or  with  a  curved,  closed  scissors,  and  in  this  manner 
to  lift  the  sac  out  without  rupture  (Fig.  28). 

If,  however,  the  sac  is  ruptured,  the  operator  need  not  fear 
that  the  contents  will  infect  the  wound.  If  this  is  a  risk  at  all, 
it  is  certainly  a  very  slight  one,  since  primary  union  regularly  fol- 
lows operation  in  all  non-inflamed  cases.  Even  when  suppuration 
is  present,  union  of  the  sutured  skin  is  often  obtainable. 


Fig.  28. 


-Operation  for  Sebaceous  Cyst  of  Scalp.     Skin  divided  to  the  sac  and 
retracted. 


If  the  sac  is  ruptured,  its  contents  should  be  at  once  evacuated, 
and  the  sac  itself  peeled  out  or  dissected  out.  If  the  cyst  is  a  large 
one,  there  will  be  considerable  redundant  skin  after  the  sac  has 
been  removed  (Fig.  29).  This  will  shrink  in  time,  so  that  it  is 
not  usually  necessary  to  cut  any  of  it  away. 

The  wound  should  be  closed  by  interrupted  sutures  of  fine 
black  silk  or  horsehair,  and  pressure  applied  most  carefully  to 
prevent  the  formation  of  a  blood  clot.     For  this  reason  a  bandage 


70 


TUMORS    AND    DEFORMITIES   OF  TTTE   DEAD 


Fig.  29. — Operation  for  Sebaceous 
Cyst  of  Scalp.  The  redundant 
skin  collapses  after  the  removal  of 
the  sac. 

feat  primary  union  if  the 
sac  is  dissected  away.  It 
does  make  it  very  difficult 
to  recognize  the  wall  of  the 
sac,  however,  and  unless  the 
wall  is  entirely  removed  re- 
currence will  take  place. 
If,  therefore,  the  abscess  is 
pronounced,  it  is  better  to 
lance  and  drain  it,  explain- 
ing to  the  patient  that  the 
sac  will  later  fill  again  with 
sebaceous  material  and  must 
then  be  removed  (Fig.  30). 

An    interesting    case    in 
which     a     tumor     growing 


aboul  the  head,  at 
leasl  for  l  wo  or  three 

days,  is  necessary,  ex- 
cept in  the  case  of  a 
very  small  cyst.  Af- 
ter that  a  cotton-col- 
lodion dressing  is 
preferable. 

A  sebaceous  cyst 
of  the  face  or  behind 
the  ear  is  more  apt  to 
suppurate  than  one 
of  the  seal}).  This 
suppuration  is  of  such 
a  mild  character  that 
it  does  not  usually  de- 


Fig.  30. — Inflamed  Sebaceous  Cyst  Behind 
the  Ear.  Of  many  months'  duration;  in- 
fected three  days. 


DERMOID  CYST 


71 


from  or  beneath  the  skull  and  lifting  the  scalp  was  erroneously 

diagnosed  as  a  sebaceous  cyst,  is  described  on  page  105  with  an 
accompanying  illustration. 

Mucous  cysts  may  appear  in  any  portion  of  the  mouth  as 
the  result  of  obstruction,  to  the  secretion  of  a  mucous  gland.  They 
are  more  common  on  the  inner  surface  of  the  lips  and  cheeks. 
They  are  extremely  thin-walled,  and  are  filled  with  a  clear,  glairy 
fluid.  It  is  not  possible  to  dissect  out  the  filmy  sac,  nor  is  this 
necessary,  for  if  a  triangular  or  circular  portion  be  cut  from  the 
mucous  membrane  overlying  the  sac,  the  latter  will  be  destroyed 
by  granulation  during  the  healing  process,  so  that  recurrence  need 
not  be  feared. 

Hanula,  or  Sublingual  Salivary  Cyst. — Sometimes  a  duct 
of  one  sublingual  gland  becomes  obstructed,  and  as  the  saliva  accu- 


Fig.  31. — Cyst  of  Sublingual  Gland — Ranula.     Existing  one  week.     Patient,  a 
woman  aged  twenty-eight  years. 


mulates  a  soft  cyst  forms  under  the  tongue  called  a  ranula  (Fig. 
31).     In  rare  cases  both  sides  are  affected  at  once.     If  the  cyst 


72  TUMORS   AND    DEFORMITIES  <>l    THE    HEAD 

is  prieked  with  a  scalpe]  n  teaspoonful  of  \  i>ci< I  opalescent  fluid 
may  be  expressed.  A  portion  of  the  wall  of  the  sac  should  be 
excised,  ami  a  rubber  tissue  drain  kepi  in  if  possible  for  several 
davs,  in  order  I"  give  the  epithelium  of  the  mouth  time  to  unite 
with  that  lining  the  cyst.  Otherwise  the  cysl  will  refill  and  the 
operation  musl  be  repeated. 

Simple  Parotid  Cyst. — A  similar  retention  cysl  may  de- 
velop from  some  portion  of  the  parotid  salivary  gland.  As  it  lies 
under  the  skin  of  the  cheek,  and  is  not  attached  to  it,  it  is  most 
readily  mistaken  for  a  lipoma.  It  should  he  removed  in  toto, 
and  if  its  attachment  to  the  gland  is  a  close  one,  allowance  must 
he  made  for  a  continued  salivary  discharge.  If  the  wound  is  com- 
pletely sutured  it  will  almost  invariably  fill  up  with  a  mixture 
of  saliva,  serum,  and  leucocytes.  It  is  hotter,  therefore,  to  leave 
a  minute  drain — for  example,  four  or  five  horsehairs  or  threads 
twisted  together  and  douhled  or  a  flat  gutta-percha  drain — in  the 
wound,  which  should  elsewhere  be  sutured.  This  will  allow  the 
slight  secretion  to  escape,  and  in  the  course  of  a  few  days  or  perhaps 
a  few  weeks  the  discharge  will  cease,  and  in  time  the  indurated 
nodule  caused  bv  the  granulation  of  the  little  cavity  will  entirely 
disappear,  leaving  not  so  delicate  a  scar  as  would  have  resulted 
from  removal  of  a  tumor  with  primary  union,  but  one  which  is 
not  very  noticeable. 

Dental  Cyst. — A  cyst  sometimes  forms  by  the  side  of  a  root 
of  a  decayed  tooth.  The  fluid  collects  slowly  and  without  the 
usual  signs  of  inflammation  (Fig.  32).  When  evacuated  it  is 
found  to  he  of  a  mucous  character  clouded  with  epithelial  debris. 
Such  a  cyst  is  thought  to  be  due  to  overgrowth  of  remnants  of 
cells  concerned  in  the  embryonic  development  of  the  teeth.  The 
cyst  forms  within  the  bone,  and  its  projecting  portion  is  partly  or 
wholly  covered  by  a  thin  layer  of  hone  which  may  crackle  when 
palpated.  The  exposed  wall  of  the  cyst  should  be  cut  away  and 
its  cavity  filled  with  iodoform  or  other  antiseptic  gauze  and  al- 
lowed to  heal  by  granulation  from  the  bottom. 

Dermoid  Cyst. — A  dermoid  cyst  is  of  congenital  origin,  and 
occurs  in  one  of  the  lines  of  embryonic  closure  of  the  skin.  It 
may  be  apparent  at  birth,  or  it  may  not  be  noticed  until  some 
years  afterward,  when  its  increase  in  size  first  attracts  the  atten- 
tion of  the  patient  or  some  friend.     Some  dermoid  cysts  are  made 


DEEMOID  CYST.  73 

up  of  a  single  layer  of  epithelium,  with  sebaceous  contents,  in 
which  a  few  hairs  are  sometimes  found.  If  the  attachment  of  the 
dermoid  cyst  to  the  deeper  structures  is  slight,  its  removal  is 
almost  as  simple  as  the  removal  of  a  sebaceous  cyst.  Some  der- 
Jnoid  cysts  have  extensive  deep  attachments,  so  that  their  removal 


Fig.  32. — Dental,  Cyst  of  Six  Weeks'  Duration.  There  was  freely  movable  skin 
and  absence  of  heat,  redness,  edema,  and  tenderness,  but  the  cyst  was  mistaken 
for  alveolar  abscess. 

is  difficult  and  may  be  followed  by  a  permanent  scar.  It  is  of  the 
greatest  importance,  therefore,  that  a  correct  diagnosis  of  dermoid 
cyst  be  made  before  its  removal  is  attempted. 

Differential  Diagnosis. — A  mistake  in  diagnosis  lies  chiefly 
between  a  dermoid  cyst  and  a  sebaceous  cyst ;  hence  the  importance 
of  considering  in  detail  the  points  of  difference.  The  common 
situations  in  which  sebaceous  cysts  are  found  have  already  been 


74 


TUMORS    AM)    DEFORMITIES   (»F  THE   HEAD 


spoken  of.  They  include  nearly  all  the  situations  in  which  a  der- 
moid cv.-t  of  the  head  is  likely  to  be  found.  Dermoids  occur 
chiefly  aboul  the  inner  or  outer  angle  of  the  orbit,  or  in  front 
of  or  behind  the  ear  (see  Figs.  33,  3  l,  and  35).  A  sebaceous  cyst 
is  rare  in  childhood;  dermoids  occur  in  infancy,  childhood,  and 
adult  life.  A  sebaceous  cysl  is  always  attached  to  the  skin  at  one 
point;  a  dermoid  is  usually  covered  by  normal,  freely  movable 
skin.     A  sebaceous  cyst  is  invariably  movable  with  the  skin  on 

the  deeper  structures; 
the  base  of  a  dermoid  is 
invariably  attached  to 
the  deep  facia  or  to  the 
periosteum,  or,  in  case 
of  the  ear,  to  the  peri- 
chondrium. This  point 
is  not  always  easy  to 
make  out,  since  the  more 
superficial  portion  of  the 
dermoid  cyst  may  swing 
back  and  forth  upon  its 
own  fixed  base,  but  to 
slide  the  cyst  as  a  whole 
backward  and  forward  is 
impossible.  Both  cysts 
plainly  fluctuate  when 
they  have  reached  a  suf- 
ficient size. 

During  the  operation 
it  will  be  noticed  that 
the  sac  of  a  dermoid  cyst 
is  usually  thicker  than 
that  of  a  sebaceous  cyst,  and  that  this  is  especially  true  of  its 
deeper  portion.  Furthermore,  the  attachment  of  its  base  will  be- 
come more  and  more  manifest  as  an  attempt  is  made  to  dissect  it 
free.  It  can  never  be  freed  by  blunt  dissection,  since  it  is  anatom- 
ically connected  with  the  deeper  tissues.  If  it  contains  hairs  the 
diagnosis  is  certain. 

A  dermoid  cyst  which  contains  little  sebaceous  matter  and  does 
not  fluctuate  may  be  mistaken  for  a  lipoma  or  a  small,  deep-seated 


Fig.  33. 


-Dermoid  Cyst  of  the  Nose,  Noticed 
Soon  After  Birth. 


DERMOID  CYST 


75 


angioma.     The  size  of  the  latter  can  always  be  reduced  by  com- 
pression, but  it  is  promptly  restored  when  the  relief  of  pressure 

allows    the    blood-vessels 

to  refill. 


Fig.  34. — Dermoid  Cyst  in  Front  of  the  * 
Ear,  Growing  for  Five  Years.     Pa- 
tient aged  twenty-two  .years. 


Fig.  35. — Dermoid  Cyst  Behind 
the  Ear,  Closely  Resem- 
bling a  Sebaceous  Cyst  in 
External  Appearance.  Pa- 
tient aged  24  years. 


Treatment. — The  incision  for  the  removal  of  a  dermoid  cyst 
near  the  orbit  should  be  made  through  the  eyebrow,  the  hair  first 
having  been  shaved  off,  or  it  should  follow  the  direction  of  a  wrinkle 
in  the  forehead  or  about  the  angle  of  the  eye,  so  that  the  scar  shall 
be  insignificant.  The  separation  of  the  overlying  skin  from  the 
cyst  is  easily  accomplished,  while  the  dissection  of  the  base  of  the 
cyst  from  the  bone  may  be  difficult.  For  this  reason,  unless  the 
patient  is  of  a  very  quiet  and  courageous  disposition,  it  is  better 
to  give  a  general  anesthetic,  as  it  is  difficult  to  obtain  complete 
anesthesia  of  the  part  of  the  cyst  adherent  to  the  periosteum  by 
means  of  cocain  or  eucain.  After  most  of  the  sac  has  been  freed, 
it  should  be  split  open  and  emptied,  so  that  the  operator  may  know 
exactly  how  far  its  cavity  extends.  Sometimes  the  cyst  can  be 
dissected  free  from  the  periosteum  without  injury  to  the  latter. 
More  often  a  part  of  its  base  is  really  formed  by  the  periosteum, 


70  TUMOKS   AM)  DEFORMITIES  OF  THE  HEAD 

so  that  the  complete  removal  of  the  cyst  will  necessitate  the  re- 
moval of  a  little  periosteum.  This  is  not  a  serious  matter,  as 
necrosis  will  not  follow  unless  the  wound  suppurates.  The  oper- 
ative wound  should  be  sutured  and  a  firm  dressing  applied  to 
obliterate  the  cavity  due  to  the  removal  of  the  cyst. 

When  the  dermoid  cyst  is  situated  in  front  of  or  behind  the 
ear,  it  may  be  so  closely  associated  with  the  cartilage  of  the  audi- 
tory canal  that  its  inner  portion  reaches  to  the  base  of  the  skull. 
Under  these  circumstances,  as  much  of  the  cyst  as  is  accessible 
should  be  removed  and  the  remainder  should  be  cauterized  with 
carbolic  acid. 

Congenital  Sinus. — The  first  pharyngeal  cleft  terminates 
just  in  front  of  the  ear.  This  is  a  region  in  which  inclusion  cysts 
and  sinuses  are  found.  Such  sinuses  are  often  similarly  placed  in 
front  of  both  ears.  They  are  usually  small,  and  being  lined  with 
the  normal  skin,  secrete  very  little.  They  may  become  obstructed 
and  form  cysts. 

The  only  satisfactory  treatment  is  the  removal  of  the  whole 
sinus  or  cyst  by  dissection.  Any  epithelial  remainders  are  apt  to 
develop  into  cysts. 

The  sinuses  formed  by  the  partial  closure  of  the  lower  phar- 
yngeal clefts  are  described  in  the  section  devoted  to  affections  of 
the  neck  (p.  137). 

BENIGN   SOLID   TUMORS 

Papilloma. — This  tumor  growing  from  the  skin  or  mucous 
membrane  usually  resembles  a  more  or  less  pedicled  wart.  It  is 
composed  of  fat  and  fibrous  tissue  covered  with  essentially  normal 
skin. 

Treatment. — It  may  be  snipped  off  level  with  the  skin,  but 
if  at  all  sessile  its  base  should  be  removed  by  two  incisions,  which 
remove  an  elliptical  portion  of  skin  containing  the  base  of  the 
tumor.  This  guards  against  recurrence,  and  permits  the  smooth 
closure  of  the  wound.  A  papilloma  of  the  lip  may  be  mistaken 
for  the  primary  lesion  of  syphilis;  that  of  the  skin  for  a  cancer 
(Fig.  36). 

Mole.  — A  mole  is  a  congenital  pigmented  fibroma  of  the  skin 
more  or  less  elevated  above  the  surface.     Sometimes  in  addition 


MOLE 


77 


to  its  excessive  pigment,  a  mole  contains  hairs  abnormally  Large 
for  the  situation  in  which  they  occur. 

While  most  moles  persist  for  life  without  undergoing  any 
change,  a  few  take  on  sarcomatous  growth,  either  on  account  of 
external  irritation  or  for  some  unknown  reason.  For  this  reason 
one  is  justified  in  removing  any  mole.  They  are  chiefly  removed, 
however,  on  account  of  their  unsightly  appearance. 

Treatment. — In  removing  a  mole,  one  should  be  careful  to 
take  away  all  the  cells  of  which  it  is  composed,  lest  those  remain- 


Fig.  36. — Papilloma  of  Skin  Occurring  in  a  Scar,  Diagnosed  as  Cancer.    The 
diagnosis  was  corrected  by  microscopical  examination.     Compare  Fig.  54,  p.  96. 


ing  be  stimulated  to  increased  growth 


For  this  reason  caustics, 
whether  chemical,  thermal)  or  electrical,  are  not  to  be  recom- 
mended. Excision  is  the  method  of  choice,  and  may  be  performed 
in  two  ways. 


78  TUMORS   AM)    DEFORMITIES  OF  THE    HEAD 

[f  the  mole  is  small  it  should  be  seized  with  fine  mouse-tooth 
forceps  and  elevated  slightly  above  the  surrounding  skin.  It  may 
then  be  snipped  off  with  a  sharp  scalpel  or  a  pair  of  curved  scis- 
sors. Xo  local  anesthetic  is  necessary.  When  the  removal  is  prop- 
erly done,  all  of  the  pigmented  tissue  is  removed,  and  in  its  place 
there  is  a  small  oval  loss  of  epithelium.  This  defect  heals  without 
permanent  scar. 

In  the  case  of  larger  moles,  especially  if  they  are  so  situated 
that  a  linear  scar  will  nn(  be  objectionable,  a  different  method  of 
■  removal  is  preferable.  The  mole  should  be  excised,  together  with 
the  underlying  portion  of  the  true  skin.  The  area  of  skin  involved 
should  first  he  cocainized.  An  ellipse  is  then  marked  out,  having 
the  mole  as  its  center.  The  cut  which  separates  this  section  of 
skin  should  everywhere  be  perpendicular  to  the  surface,  in  order 
that  the  cut  edges  may  fit  exactly  when  sutured.  The  removal  of 
the  elliptical  portion  of  skin  is  sometimes  followed  by  hemorrhage. 
This  can  usually  be  stopped  by  a  few  minutes'  pressure,  or  by 
crushing  the  bleeding  vessel  with  an  artery  forceps.  The  next 
step  is  to  undermine  the  surrounding  skin  for  a  distance  of  a  third 
of  an  inch  or  less,  so  that  the  tension  upon  the  sutures  may  be 
slight.  If  the  skin  is  lax,  as  it  is  about  the  eyes,  this  step  may 
be  safely  omitted.  If  the  skin  is  firm  and  is  not  undermined,  the 
scar  may  stretch  after  the  removal  of  the  sutures  until  it  is  nearly 
as  broad  as  the  portion  of  skin  which  was  removed. 

One  or  two  horsehair  or  fine  silk  sutures  should  be  inserted. 
It  is  well  to  remove  these  in  three  or  four  days,  so  that  there  may 
be  no  permanent  marks  to  indicate  the  stitch  holes.  Tension  upon 
the  scar  may  thereafter  be  reduced  by  a  strip  of  adhesive  plaster. 

Lipoma. — A  lipoma  is  a  tumor  composed  of  fat  with  a  mini- 
mum of  fibrous  tissue.    It  usually  has  a  well-marked  capsule. 

Lipoma  of  the  face  is  most  often  found  in  the  forehead,  where 
it  forms  a  smooth,  flattened  tumor  usually  about  three-fourths  of 
an  inch  in  diameter  (Fig.  37).  Its  attachment  to  the  skin  is 
slight,  being  noticeably  less  than  the  attachment  of  a  sebaceous 
cyst.  Moreover,  the  tension  within  the  sac  of  a  sebaceous  cyst  is 
usually  greater  than  that  within  the  capsule  of  a  lipoma.  It  is 
well  known  that  an  encapsulated  tumor  will  sometimes  fluctuate, 
although  it  contains  no  fluid.  This  is  particularly  true  of  a  lipoma 
of  the  forehead,  wdrich  gives  just  as  good  a  fluctuation  wave  on 


FIBROLIPOMA 


79 


account  of  the  hard  bone  beneath  it  as  a  sebaceous  cyst  can  give. 
A  sebaceous  cyst  is  more  globular  than  a  lipoma,  and  projects  far 
more  above  the  level  of  the  surrounding  skin  (cf.  Fig.  20,  p.  67). 

Treatment. — If  left  alone  a  lipoma  shows  little  tendency  to 
increase  in  size,  but  it  is  so  conspicuous  that  its  removal  is  desir- 
able. This  is  easily  accomplished  if  the  lobules  of  fat  are  large 
and  the  capsule  well  defined. 

The  skin  is  cocainized,  and  an  incision  made  across  the  center 
of  the  lipoma  in  the  direction  in  which  the  scar  will  be  least  con- 
spicuous. This  is  in 
a  horizontal  direction 
in  the  case  of  the 
forehead.  The  inci- 
sion should  divide 
the  skin  and  also  the 
capsule  of  the  lipo- 
ma. When  this  has 
been  done,  the  li- 
poma itself  can  be 
shelled  out  by  blunt 
dissection  with  little 
difficulty.  If  one 
finds  the  dissection 
difficult,  it  is  certain 
that  he  is  not  fol- 
lowing the  plane  be- 
tween the  capsule 
and  the  lipoma 
proper.  As  this  tu- 
mor shows  mo  incli- 
nation to  recur,  it  is 
unnecessary  to  re- 
move the  capsule. 

The  wound  should  be  closed  by  interrupted  sutures,  or  the  sutures 
may  be  omitted,  since  in  this  situation  there  is  little  tendency  for 
the  cut  edges  to  retract.  The  best  dressing  is  a  cotton-collodion 
one. 

Fibrolipoma. — A  fibrolipoma  of  the  head  has  the  usual 
characteristics   of  this  tumor  when  found  in  other  portions  of 


Fig.  37. — Lipoma  of  Forehead,  Duration  One  Year. 


so 


TUMORS    AND   DEFORMITIES   OF  THE   HEAD 


in   Figure  38 


the  body  i  p.  L85  ).    A  fibrolipoma  in  an  unusual  situation  is  shown 
Its  attachmenl   was  to  the  skin  of  the  external 
auditory  canal. 

Angioma. — Angioma  of 
the  face  is  of  common  oc- 
currence in  early  infancy. 
A  small  patch  of  dilated 
capillaries  and  veins,  often 
culled  ;i  nevus,  may  be  pres- 
ent at  birth.  This  lesion  in- 
creases rapidly,  so  that  early 
treatment  is  desirable  in  or- 
der to  avoid  unsightly  deform- 
ity. The  vessels  dilated  are 
usually  those  of  the  super- 
ficial portion  of  the  skin,  al- 
though in  some  instances  the 
deeper  vessels  alone  are  af- 
fected, or  it  may  be  that  the 
center  of  the  nevus  reaches 
the  surface  of  the  skin  while 
its  edges  extend  into  the 
deeper  portions  of  the  skin, 
but  are  covered  with  normal  epithelium.  If  the  angioma  reaches 
the  surface  it  can  scarcely  be  confounded  with  anything  else,  but 
a  deep  angioma  containing  much  fibrous  tissue  may  be  taken  for 
a  fibrolipoma.  Possibly  a  contusion  with  hemorrhage  into  the 
loose  tissue  around  the  eyelids  might  be  mistaken  for  a  commenc- 
ing nevus,  but  the  lapse  of  a  few  days  would  suffice  to  distinguish 
the  two.  Pressure  upon  a  vascular  tumor  empties  its  vessels  and 
makes  it  white.  As  soon  as  the  pressure  is  removed,  the  vessels 
immediately  refill.  Pressure  upon  effused  blood  causes  its  disap- 
pearance only  to  a  slight  degree.  This  difference  is  most  strik- 
ingly shown  if  the  pressure  be  made  with  a  bit  of  transparent  glass, 
so  that  the  effect  can  be  seen  through  it. 

Treatment. — Capillary  angiomata  are  successfully  treated  by 
punctures  with  a  fine  needle  which  constitutes  the  negative  pole  of 
an  electric  battery.  For  this  purpose  the  battery  should  contain 
from  a  dozen  to  thirty  small  cells.     The  positive  pole  should  be  a 


Fig.  3S. — Fibrolipoma  of  Auditory  Ca- 
nal, Duration  One  Year.  Patient, 
aged  nineteen  years. 


ANGIOMA  81 

moist  sponge,  while  a  fine  cambric  needle  or,  better  still,  a  jeweler's 

brooch  is  screwed  into  the  handle  co acted  with  the  negative  pole, 

The  sponge  is  held  closely  against  the  face,  while  the  needle  is 
thrust  into  the  skin  at  right  angles  to  its  surface  from  one-fourth 
to  one-third  of  an  inch.  It  is  important  that  the  needle  inserted 
should  he  the  negative  pole,  for  if  it  is  the  positive  pole  bubbles 
of  oxygen  will  form  around  it  and  will  produce  upon  it  oxid  of 
iron,  some  of  which,  remaining  in  the  tissues  after  the  needle  is 
withdrawn,  may  cause  a  permanent  discoloration.  The  current 
should  be  sufficiently  strong  to  produce  a  white  zone  about  the 
needle  one-eighth  of  an  inch  in  diameter  in  ten  or  twenty  seconds. 
If  it  is  too  strong  the  escharotic  action  is  too  vigorous  and  a  per- 
manent scar  is  produced.  If  it  is  too  weak  the  cauterization  is 
insufficient  and  the  puncture  is  apt  to  bleed  badly  when  the  needle 
is  withdrawn.  If  the  battery  is  freshly  filled,  eight  or  ten  cells 
are  usually  sufficient.  Half  a  dozen  punctures  may  be  made  at 
one  sitting,  and  the  treatment  may  be  repeated  twice  a  week.  The 
pain  is  intense,  and  a  cool  assistant  is  required  to  hold  the  head 
and  arms  of  the  child.  IsTo  anesthetic  is  required,  as  the  pain  does 
not  continue  after  the  removal  of  the  needle,  and  even  a  delicate 
baby  suffers  no  injury  from  the  treatment.  If  the  punctures  are 
judiciously  made,  and  the  treatment  is  continued  until  every  red 
vessel  disappears,  a  satisfactory  result  will  be  obtained  in  most 
instances,  and  in  place  of  the  angioma  there  will  be  a  cicatrized 
area  marked  here  and  there  by  little  pits  due  to  too  vigorous  cau- 
terization. If  the  nevus  is  wholly  superficial  and  only  capillaries 
are  involved,  the  scar  will  be  extremely  slight.  The  site  of  a 
deeper  tumor,  especially  if  it  contains  larger  vessels,  will  be 
marked  by  a  thickened  and  more  abnormal  patch  of  skin.  It 
may  be  of  advantage  to  perform  a  partial  excision  of  such  a  nevus 
at  some  stage  of  the  treatment  by  electrolysis. 

Another  method  of  treatment  by  which  good  results  are  ob- 
tained is  the  coagulation  of  blood  in  the  vessels  by  the  injection 
into  the  nevus  of  a  few  drops  of  water  almost  at  the  boiling  point. 
The  effect  of  heat  applied  in  this  way  should  be  great  enough  to 
produce  coagulation,  as  shown  by  the  immediate  pallor  in  the 
portion  of  the  nevus  so  treated.  After  a  few  days  the  permanent 
effect  of  the  treatment  will  be  manifest,  and  if  red  spots  remain 
additional  injections  should  be  made. 


82  TUMORS   AND   DEFORMITIES   OF  THE   HEAD 

Treatment  by  Operation. — If  an  angioma  is  made  up  of 

larger  vessels,  either  veins  or  arteries,  it  is  readily  compressible 
and  may  pulsate  (Figs.  39  and  40).  Electrolysis  is  useless  in 
such  a  case,  and  the  tumor  must  be  removed  by  operation  or  its 


Fig.  39. — Pulsating  Angioma  of  Scalp,  Congenital.      The  photograph  shows  it 

fully  distended. 

vessels  ligated.  This  operation  is  serious  in  the  case  of  an  infant, 
for  the  bulk  of  its  blood  is  so  small  that  it  will  succumb  to  a 
hemorrhage  which  does  not  seem  large  to  one  accustomed  to  oper- 
ate only  upon  adults.  Even  when  the  operation  is  upon  an  adult, 
every  precaution  should  be  taken  to  limit  the  hemorrhage.  There 
should  be  plenty  of  artery  clamps  at  hand.  One  assistant  should 
have  nothing  to  do  except  to  control  hemorrhage  by  pinching  the 
surrounding  skin  or  pressing  it  against  the  skull.  Even  then  the 
bleeding  will  not  be  under  perfect  control,  since  the  vessels  of  the 
tumor  often  anastomose  with  the  veins  inside  of  the  skull.  As 
fast  as  the  incision  is  made  the  cut  vessels  should  be  clamped.  Tf 
there  is  plenty  of  skin  to  cover  the  wound  without  using  any  of 


ROSACEA  HYPERTROPHIC^  83 

that  which  covers  the  vessels  of  the  tumor,  the  whole  incisioE 
should  be  made  before  the  base  of  the  tumor  is  cut  into.  In  this 
way  much  of  its  blood-supply  will  be  shut  off  before  the  most  dif- 
ficult part  of  the  operation,  namely,  the  dissection  of  the  base,  is 


Fig.  40. — Same  Tumor  as  Fig.  39,  but  Photographed  Immediately  after  the 
Fingers  which  were  used  to  Compress  the  Tumor  had  been  Removed.  As 
the  volume  of  the  tumor  increased  very  rapidly  when  released,  this  figure  does 
not  show  it  at  its  smallest. 

attempted.  If  the  skin  of  the  tumor  is  needed,  one  lateral  inci- 
sion should  be  made,  the  base  next  dissected,  and  the  collapsed 
tumor  cut  away  from  as  much  of  the  overlying  skin  as  is  needed 
to  cover  the  wound,  which  should  be  accurately  closed  by  suture. 
The  dressing  should  be  a  firm  one,  but  sufficiently  elastic,  so  that 
the  pressure  exerted  may  not  threaten  the  vitality  of  the  skin. 

Rosacea  Hypertrophica,  or  Hhinophyma. — This  is  an 
overgrowth  of  the  nose,  which  is  generally  considered  to  be  one  of 


84  TUMORS  AND   DEFORMITIES  OF   THE    HEAD 

the  forms  of  rosacea,  but  is  here  included  with  the  tumors  to  which 
ii  belongs  clinically,  for  the  appearance  of  the  lesion  and  the  treat- 
liicni  warranl  this  classification  (Fig.  4  1). 

This  is  a  disease  of  middle  life,  or  later,  marked  by  a  great 
overgrowth  of  the  sebaceous  follicles,  with  their  duds,  as  well  as 
of  blood-vessels  and  fatty  tissue.  The  skin  itself  is  not  greatly 
thickened,  and  may  even  be  thinned,  apparently  the  result  of  over- 
stretching it.     The  tumor  as  a  whole  is  soft  and  flabby,  of  dark  red 


Fig.  41. — Rosacea  Hypertrophica  of  the  Nose,  of  Seven  Years'  Duration. 
Patient  aged  sixty-nine  years. 

color,  due  to  the  venous  congestion.  It  is  not  necessarily  the  result 
of  alcoholism,  and  many  of  these  patients  are  unjustly  accused  of 
intemperate  habits. 

Lesser  degrees  of  hypertrophic  rosacea  of  the  nose  are  fre- 
quently found.  Such  an  extreme  overgrowth  as  is  shown  in  Fig- 
ures 42  and  43  is  decidedly  exceptional,  although  even  more 
marked  instances  are  occasionally  seen. 

Although  this  overgrowth  is  benign  in  character,  the  excess  of 


rosacea  hypehthophica 


85 


tissue  should  be  removed,  as  this  can  be  accomplished  without 
much  risk,  and  the  feelings  of  the  patient  will  thereby  be  spared 
many    mortifying    re- 


marks. 

Treatment. — This 
consists  in  the  re- 
moval of  wedge- 
shaped  pieces  of  the 
growth,  so  that  the 
normal  contour  of  the 
nose  may  be  restored. 
The  spongy  tissue  is 
very  insensitive,  so 
that  a  small  amount 
of  a  dilute  solution  of 
eucain  or  cocain  is 
sufficient.  IT  e  m  o  r  - 
rhage  is  free,  but  may 
be  controlled  by  pres- 
sure and  ligatures. 
Although  these  pa- 
tients are  usually 
plethoric  and  stand 
very  well  the  loss  of 
blood,  it  may  be  ad- 
visable to  remove 
only  a  portion  of  the 
growth  at  one  sitting. 
This  plan  has  the  fur- 
ther advantage  of  en- 
abling the  surgeon  to 
observe  the  effect  of  a 
partial  removal  of  the 
tumor  before  complet- 
ing the  task.  Ee- 
moval  may  be  effected 
in  such  a  way  that 
pedicled  flaps  are  uti- 
lized to  cover  the  raw 


Fig.  42. — Rosacea  Hypertrophica   of  the  Nose, 
Four  Years'  Duration.     Front  view. 


Fig.  43. — Same  Subject  as  Fig.  42.     Side  view. 


S6 


TOMOHS     WD    DIMDKMITIES  OF  THE   HEAD 


^H 

ft  V    .■  Mk  ■■ 

■-, 

■ 

1                    1  ,9 

Fig.  44. — Same  Subject  as  Fig.  42,  Showing  the 
Results  of  Operative  Treatment  for  Rosa- 
cea Hypertrophica  of  the  Nose;  Three  Weeks 
After  First  Operation,  and  One  Week  After 
Second  Operation. 


Fig.  45. — Same  Subject  as  Fig.  42.     Side  view,  one 
week  after  the  second  operation. 


spaces.  Their  vital- 
ity is  low,  and  unless 
the  pedicle  is  very 
1 1 road,  they  arc  likely 
to  slough.  There- 
fore it  is  advisable 
not  to  undermine 
them  too  extensively. 

The  results  of  I  Ids 
plastic  surgery  arc 
\rvy  satisfactory 
(Figs.  44  and  45). 
Tn  sonic  cases,  if  the 
quality  of  the  skin  is 
too  poor,  it  is  better 
to  shave  off  all  of 
the  tissue  down  to 
the  cartilage  and  to 
cover  the  wound  with 
skin  grafts. 

Hypertrophy 
of  the  Tonsil  and 
other  Lymphoid 
Structures  in  the 
Naso-pharynx  and 
Pharynx.  —  The 
fancial  tonsil  is  fre- 
quently enlarged,  es- 
pecially iu  children, 
either  as  a  sequence 
of  repeated  attacks  of 
tonsillitis  or  of  sonic 
other  infections  dis- 
ease, such  as  scarlet 
fever,  diphtheria,  or 
measfes.  In  children 
hypertrophy  of  the 
tonsils  is  frequently 
associated    with    hy- 


HYPERTROPHY  OP  THE  TONSIL  87 

pertrophy  of  the  lymphoid  tissue  in  the  naso-pharynx,  commonly 
called  adenoids,  with  hypertrophy  of  the  lymphoid  tissue  at  the 
base  of  the  tongue,  the  so-called  lingual  tonsils,  and  enlargement 
of  the  cervical  lymphatic  glands. 

Symptoms  produced  by  tonsillar  hypertrophy  may  be  very 
slight,  or  the  enlargement  may  be  sufficient  to  interfere  with  nor- 
mal swallowing  and  to  favor  and  make  more  severe  attacks  of  acute 
tonsillitis.  Adenoids  often  obstruct  the  posterior  nares  to  such  an 
extent  that  the  patient  breathes  through  his  mouth  when  asleep, 
and  sometimes  during  the  day  as  well.  For  these  reasons,  sur- 
gical treatment  is  frequently  indicated. 

Diagnosis. — The  diagnosis  of  hypertrophy  of  the  tonsils 
is  made  by  direct  inspection.  If  one  can  see  them  during  a 
period  of  acute  inflammation,  as  well  as  in  the  intervals  be- 
tween such  attacks,  he  can  best  judge  of  the  necessity  for  their 
removal. 

The  diagnosis  of  hypertrophy  of  the  lingual  tonsil  is  made 
from  the  image  reflected  in  a  throat  mirror. 

The  diagnosis  of  adenoids  is  made  from  the  image  reflected 
in  a  rhinoscopic  mirror,  when  this  can  be  obtained.  It  can  also 
be  made  by  palpation  with  the  forefinger,  and  can  be  assumed 
from  persistent  mouth  breathing,  especially  if  the  anterior  nares 
are  not  obstructed.  There  is  also  an  alteration  in  the  sound  of 
the  voice,  and  a  postnasal  catarrh.  In  extreme  cases  the  facial 
expression  is  altered.     Partial  deafness  may  result. 

Treatment. — Tonsilectomy  is  the  term  applied  to  the  removal 
of  a  hypertrophic  tonsil.  The  ancient  practise  of  destroying  a  por- 
tion of  such  a  tonsil  by  the  cautery,  or  merely  excising  the  pro- 
jecting portion,  has  largely  yielded  its  place  to  a  complete  removal 
of  the  tonsil.  This  may  be  done  under  a  local  or  a  general  anes- 
thetic. The  choice  depends  more  on  the  character  of  the  indi- 
vidual than  on  the  condition  of  the  tonsils.  Those  called  for  the 
first  time  to  operate  upon  a  young  child  will  do  well  to  employ  a 
general  anesthetic. 

The  mouth  is  opened,  a  mouth  gag  inserted,  the  tonsil  seized 
with  a  slightly  curved  forceps  having  two  or  three  prongs,  and 
lifted  from  its  bed.  It  may  then  be  cut  off  with  a  tonsillotome, 
or  dissected  with  scissors  or  a  knife.  If  the  latter  method  is 
chosen,  it  is  only  necessary  to  divide  the  mucous  membrane ;  the 


Fig.  40. — Instruments  Used  rem  the  Removal  of  the  Tonsil.  A,  tonsillo- 
tome  (this  instrument  is  not  used  by  many  operators) ;  B,  mouse-tooth  forceps; 
C,  sponge  holder,  of  winch  several  should  be  at  hand;  D,  E,  blunt  pointed  knives; 
F,  tongue  depressor;  G,  mouth  gag;  H,  tonsil  forceps;  7,  long  curved  forceps; 
J ,  long  curved  scissors. 


HYPERTROPHY  OF  THE  TONSIL  89 

tonsil  can  then  be  shelled  from  its  Led  by  blunt  dissection  with 
the  finger  or  a  suitable  instrument.  In  this  manner  the  whole 
tonsil  can  be  removed  more  perfectly  than  with  a  tonsillotome 
(Fig.  46). 

If  a  local  anesthetic  is  decided  upon,  the  mucous  membrane 
should  be  anesthetized  by  the  application  of  a  strong  solution  of 
cocain  or  stovain,  ten  or  twenty  per  cent.  There  is  less  danger 
of  poisoning  if  the  anesthetic  is  applied  upon  a  swab  rather  than 
in  the  form  of  a  spray,  but  the  swab  should  not  be  so  wet  as  to 
allow  the  solution  to  trickle  down  the  throat.  Another  good  plan 
is  to  inject  a  few  drops  of  a  ten  per  cent  solution  of  stovain  in 
adrenalin,  1 :  2,000,  into  the  tissues  before  beginning  the  dis- 
section. 

Hemorrhage  following  the  removal  of  the  tonsil  is  free,  but 
usually  subsides  promptly.  It  is  well  to  have  at  hand  small 
sponges  in  curved  clamps,  which  can  be  squeezed  out  of  an  adren- 
alin solution  and  pressed  firmly  against  the  bleeding  surface. 
An  astringent  gargle  is  also  serviceable.  The  patient  should  gar- 
gle the  throat  every  few  hours  with  iced  Dobell's  solution  some- 
what diluted.  In  most  cases  the  pain  which  results  is  surprisingly 
slight,  considering  the  extent  of  raw  surface  which  results  from 
this  operation. 

Hypertrophy  of  the  lingual  tonsil,  giving  rise  to  persistent 
cough  or  husky  speech,  may  require  operation.  The  excess  of 
tissue  can  be  removed  with  a  galvanocautery  or  a  specially  con- 
structed tonsillotome. 

Treatment  of  Adenoids. — Although  adenoids  tend  to 
atrophy  about  the  period  of  puberty,  it  is  unwise  to  wait  for  their 
spontaneous  disappearance,  if  they  give  rise  to  definite  symptoms 
as  described  above.  They  should  be  removed  by  operation,  pref- 
erably under  a  general  anesthetic,  although  the  postnasal  space 
is  readily  anesthetized  by  a  ten  per  cent  solution  of  cocain  in  a 
1 :  2,000  solution  of  adrenalin  chlorid,  applied  on  cotton  wound 
on  a  bent  probe. 

If  the  child  is  chloroformed,  it  may  lie  with  its  head  lower 
than  its  shoulders,  or  not,  according  to  the  operator's  preference. 
In  any  case,  a  mouth  gag  is  inserted  and  the  adenoids  are  removed 
either  with  a  specially  curved  curette  or  with  a  pair  of  forceps, 
or,  as  many  prefer,  with  the  finger  nail  (Fig.  47). 


90 


TUMORS    AND    DEFORMITIES   OF  THE  HEAD 


Following  operation,  the  nose  and  throat  should  be  frequently 
sprayed  with  a  diluted  Dobell's  solution,  or  some  other  dilute  dis- 
infectant. 


Fig.  47. — Instruments    Used   for   the   Removal  of  Adexoids. 
pressor;  B,  mouth  gag;    C,  adenoid  curettes. 


^4,  tongue   de- 


Epulis. — A  growth  which  resembles  a  papilloma  in  appear- 
ance, but  which  is  much  denser,  is  called  an  epulis.  It  usually 
springs  from  the  gum,  along  the  outer  side  of  the  molar  teeth.  As 
it  grows  it  takes  on  the  shape  of  the  space  in  which  it  lies,  and 
therefore  appears  to  have  a  broad  attachment.  When  it  is  lifted 
up  from  the  mucous  membrane  it  will  often  be  seen  to  have  an 
extremely  narrow  pedicle.  It  is  a  dense  hard  tumor,  covered  with 
mucous  membrane  having  a  normal  appearance. 

An  epulis  grows  slowly,  and  without  pain,  but  it  should  be 
thoroughly  removed  because  of  its  constant  tendency  to  increase 
in  size,  and  also  because  in  structure  it  closely  resembles  a  spindle- 
cell  sarcoma.     If  the  growing  base  of  the  tumor  in  the  mucous 


OKTIOOMA,    OH   EXOSTOSIS 


91 


membrane  is  excised,  it  is  not  likely  to  recur.  The  specimen 
should  in  all  cases  he  examined  microscopically. 

Otoliths. — Calcareous  bodies,  called  otoliths,  often  form  in 
the  fatty  portion  of  the  ear.  They  are  similar  in  character  to  the 
deposits  which  are  found  elsewhere  in  the  body  in  gouty  indi- 
viduals. In  the  ear  these  discrete  nodules  may  be  so  large  as  to 
be  noticeable  and  to  annoy  the  patient.  They  are  easily  removed 
through  small  incisions. 

Osteoma,  or  Exostosis. — This  is  a  benign  tumor,  being  a 
simple  outgrowth  of  bone.  It  is  easily  recognized  as  having  the 
consistence  of  bone,  to  which  it  is  firmly  attached.  It  is  covered  by 
normal  skin,  fat,  etc.     Such  a  tumor  is  very  rare  in  the  face  (Fig. 


Fig.  48. — Exostosis  of  Jaw.     Two  or  three  years'  duration. 

48).  It  is  commoner  in  the  skull.  If  it  is  decided  to  remove  it, 
the  skin  and  other  parts  should  be  divided  and  reflected  so  as  to 
expose  the  exostosis.  This  should  be  chiseled  away,  together  with 
the  periosteum  which  covers  it,  as  the  possibility  of  recurrence 


92  TUMOKS  AND  DEFORMITIES  OF  THE  HEAD 

should  bo  boruo  in  mind.  While  this  operation  takes  only  a  few 
minutes,  it  is  difficult  to  anesthetize  bone.  Therefore,  during'  the 
chiseling  the  patient's  sensibilities  should  be  benumbed  by  chloro- 
form of  nitrous  oxid  gas,  or,  if  preferred,  the  whole  operation 
may  be  performed  under  a  general  anesthetic.  Such  tumors  should 
be  examined  microscopically. 

Spur. — An  exostosis,  or  a  cartilaginous  tumor  projecting  from 
the  floor  or  septum  of  the  nose  and  covered  with  normal  mucous 
membrane,  is  called  a  spur.  If  of  sufficient  size  to  interfere  with 
normal  breathing,  it  should  be  removed  with  a  blunt-pointed  saw, 
the  parts  having  been  first  anesthetized  by  the  application  of  co- 
cain  or  stovain  upon  a  cotton  swab.  Bleeding  may  be  controlled 
by  adrenalin,  or  by  the  tip  of  a  galvanocautcry,  an  instrument 
which  is  utilized  by  some  for  the  removal  of  the  spur. 

Deviation  of  the  nasal  septum  is  considered  on  page  109. 

MALIGNANT   TUMORS 

Epithelioma. — An  epithelioma  may  develop  in  any  portion 
of  the  epithelium  covering  the  head  or  lining  its  cavities.  'It  is 
common  at  the  mucocutaneous  junctions  of  the  eyes,  ears,  nose, 
and  mouth  (Fig.  49). 

Its  origin,  like  that  of  malignant  tumors  in  all  situations  of 
the  body,  is  sometimes  apparently  due  to  a  wound  or  to  a  long- 
continued  irritation,  but  often  such  a  provoking  cause  seems  want- 
ing. Sometimes  a  wart  or  mole  which  has  remained  of  essentially 
the  same  size  for  years  will  begin  to  grow  rapidly,  and  if  not 
removed  will  develop  characteristics  of  a  malignant  tumor.  In 
other  cases  the  tumor  starts  as  an  ulcer  almost  from  the  beginning. 

It  is  in  the  class  of  cases  in  which  a  simple  wart  or  mole  as- 
sumes malignant  development  that  surgery  has  an  important  part 
to  play.  A  patient  may  have  noticed  such  a  localized  thickening 
of  the  epithelium  as  is  shown  in  Figures  50  and  51  for  years. 
Gradually  the  cells  begin  to  multiply  and  the  tumor  increases  a 
little  in  size.  This  should  inevitably  be  the  sign  for  removal  of  the 
growth.  At  this  stage  it  has  not  begun  to  infiltrate  the  skin.  Nor 
has  it  extended  into  the  deeper  tissues.  Hence  a  radical  cure  can 
be  effected  by  the  removal  of  the  tumor  without  any  of  the  sur- 
rounding tissues.     Such  a  simple  operation  can  be  performed  in  a 


EPITHELIOMA 


93 


few  minutes  under 
local  anesthesia,  and 
need  not  be  followed 
by  any  permanent  scar. 
On  this  account  a  pa- 
tient will  readily  con- 
sent to  the  operation. 

"While  it  is  prob- 
able that  many  of  these 
hitherto  benign  tumors 
will  never  become  ma- 
lignant, it  is  certain 
that  some  of  them  will 
do  so,  and  in  any  event 
the  operation  frees  the 
patient  of  an  annoying 
blemish.  Those  that 
develop  into  malignant 
growths  infiltrate  the 
skin  and  ulcerate  in 
the  older  portions,  and 
gradually  assume  the  usual  characteristics  of  carcinoma  of  the  sur- 
face with  an  elevated  growing  margin,   usually  of  an  irregular 


Fig.  49. — Epithelioma  of  Face  near  Nose. 
ration  six  years;   slight  ulceration. 


Fig.  50. — Epithelioma  of  the  Lip  Developing  in  a  Soft  Wart  which  had  Existed 
since  Childhood.  New  growth  noticed  nine  months  previous.  Patient  aged 
fifty-six  years.     A  similar  wart  on  nose  has  recently  shown  increased  growth. 


94  TUMORS   AND    DEFORMITIES  OF  THE  HEAD 

character.  But  even  at  this  stage  epithelioma  of  the  face  is  no! 
of  rapid  growth,  and  a  year  or  so  may  elapse  before  the  tumor 
reaches  the  diameter  of  an  inch.     This  is  equally  true  whether  the 


Fig.  51. — Same  Subject  as  Fig.  50,  Three  Months  after  Removal  of  the  Epi- 
thelioma of  Lip.  The  scar  could  only  be  seen  by  close  inspection;  one  of  the 
advantages  of  early  operation. 

tumor  is  at  first  of  the  papillomatous  type  (Fig.  52),  or  whether 
it  early  infiltrates  the  skin  and  ulcerates  (Fig.  53). 

Epithelioma  of  the  face  in  some  individuals  progresses  so 
slowly  that  the  patient  will  live  for  years,  the  tumor  gradually 
eating  away  more  and  more  of  the  skin  and  suffering  in  its  own 
turn  from  ulcerative  processes  until  possibly  the  skin  of  half  the 
face  is  in  this  manner  disintegrated.  Such  epithelioma  is  known 
as  rodent  ulcer. 


EPITHELIOMA 


95 


Diagnosis. — The  appearance  of  a  well-developed  epithelioma 

is  characteristic.  First  there  is  the  very  hard  infiltration  of  the 
skin  with  the  cancer  cells.  This  raises  the  level  of  Hie  skin  affected 
above  that  of  the  normal  surrounding  skin.  The  blood-vessels  in 
the  skin  involved,  and  in  that  adjacent  to  the  new  growth,  are  often 
dilated.  As  induration  extends,  the  blood-supply  may  be  shut  off 
from  the  older  portions  of  the  growth  and  ulceration  result.  The 
discharge  from  the  surface  of  such  an  ulcer  often  has  a  gangrenous 
odor.  The  regional  lymph-glands  may  be  swollen  and  hard.  This 
may  be  the  result  of  metastasis  or  of  the  absorption  of  septic  prod- 
ucts if  an  ulcer  exists.    As  a  diagnostic  sign  of  cancer  it  has  there- 


Fig.    52. — Epithelioma   of   the   Nose,    Recently   Growing   Rapidly.     Diagnosis 
merely  clinical,  as  the  patient  would  not  permit  removal  of  the  tumor. 


fore  a  greater  value  when  the  skin  is  unbroken  than  it  has  after 
an  ulcer  forms.  The  late  diagnosis  is  of  little  value  to  the  patient. 
The  early  diagnosis  is  life-saving. 

A  beginning  epithelioma  may  be  mistaken  for  a  wart  or  papil- 
loma (Fig.  54).     If  there  is  any  doubt  a  microscopic  examination 


Fig.  53. — Epithelioma  of  the  Cheek,  Existing  Two  Years  in  a  Man  Aged 
Si  yexty-Two. 


Fig.  54. — Epithelioma  of  Face;  Supposed  Wart  Snipped  off  Five  Weeks  before 
this  Photograph  was  Taken.     Compare  Figure  36,  page  77. 
96 


EPITHELIOMA 


97 


should  be  made  or  the  tumor  should  be  removed.  In  fact,  every 
such  tumor  which  shows  a  tendency  to  grow,  should  be  promptly 
excised.  When  this  is  done  at  an  early  stage,  before  the  tumor 
begins  to  infiltrate  the  skin,  it  is  unnecessary  to  sacrifice  any  of 
the  surrounding  skin,  and  no  disfiguring  scar  follows.  Hence  a 
patient  is  more  likely  to  submit  to  operation  at  this  early  stage, 
which  is  sometimes  spoken  of  as  the  precancerous  stage.  Micro- 
scopical examination  of  the  removed  tissue  will  sometimes  show 
that  this  term  "  precancerous  "  is  not  justified  (see  Figs.  57,  58, 
and  59,  and  the  description  of  them  on  p.  98). 

Epithelioma  of  the  Scalp. — The  early  appearance  of  epitheli- 
oma in  the  scalp  is  that  of  a  slightly  elevated  irregular  tumor,  the 


Fig.  55. — Epithelioma  of  the  Scalp  Occurring  in  a  Woman  Aged  Fifty-eight. 

surface  of  which  is  redder  in  places  than  the  normal  scalp,  and 
which  is  partly  covered  by  the  crusts  which  are  prone  to  form 
upon  the  scalp  whenever  it  is  irritated  (Fig.  55). 

Illustrations  showing  different  types  of  early  epithelioma  of 
the  face  have  been  given  in  the  preceding  pages. 

Epithelioma  of  the  Lip. — One  type  of  early  epithelioma  of  the 
lip  is  shown  in  Figure  56;  the  ulcer  of  which  was  said  to  have  ex- 
isted only  four  weeks.    Another  case  in  which  ulceration  was  of  the 


98 


TUMORS   AND   DEFORMITIES   OF  THE  HEAD 


. 


Fig.  .56. — Epithelioma  of  the  Lip,  said  to  be  of 
Four  Weeks'  Duration.  Patient  aged  forty- 
two  years. 


most  superficial  character,  although  the  tumor  had  Lasted  one  year, 
is  shown  in  Figure  60,  page  101.  This  is  a  favorite  scat  for  epithe- 
lioma. It  often  follows  long-continued  smoking  of  a  clay  pipe, 
arising  at  the  point  where  the  hot,  rough  stem  of  the  pipe  has 
rested  upon  the  lower  lip.     It  begins  as  a  slight  induration  which 

the  patient  scarcely 
notices  until  little 
scales  form  upon  the 
surface  or  a  very  shal- 
low Ulcer a1  ion  pro- 
duces slight  crusts. 
These  from  lime  to 
time  are  picked  off  or 
fall  off,  but  the  ex- 
coriation fails  to  heal. 
In  the  meantime  the 
induration  spreads 
slightly  or  creeps  into 
the  deep  tissues,  but 
for  many  months,  by  reason  of  its  limited  extent  and  lack  of  pain, 
the  patient  may  look  upon  the  lesion  as  unimportant. 

Epithelioma  of  the  Tongue. — Early  appearances  of  epithelioma 
of  the  tongue  are  shown  in  Figures  57,  58,  and  59.  Attention  is 
especially  called  to  the  two  types  of  lesion  there  shown — namely, 
the  milky  white  patches  of  leucoplakia  which  had  existed  for  sev- 
eral years,  and  the  elevated,  warty  nodules  which  had  existed  for 
some  months  at  least.  In  neither  of  these  had  the  epithelial  cells 
begun  to  grow  downward  at  the  time  the  drawing  was  made.  All 
of  the  mature  cancerous  growth  for  which  this  tongue  was  re- 
moved came  from  an  ulcer  on  its  left  margin,  which  does  not  show 
in  this  drawing. 

The  chief  possibility  of  error  in  the  early  diagnosis  of  epi- 
thelioma of  the  face  lies  in  mistaking  for  it  the  primary  lesion  of 
syphilis.  As  already  pointed  out  (page  60)  the  primary  sore 
upon  the  thick  epithelial  layer  of  the  skin  or  even  of  the  lips  or 
tongue  has  quite  a  different  appearance  from  the  primary  sore  upon 
the  more  delicate  epithelium  of  the  head  of  the  penis. 

Besides  illustrating  the  early  appearance  of  epithelioma  of  the 
tongue,  Figures  57  to  59  show  how  misleading  the  negative  micro- 


Fig.  57. — Epithelioma  op  the  Tongue,  Showing  Milky  White  Patches  of  Leuco- 
plakia,  and  papillomatous  growths,  especially  in  the  median  llne  of  the 
Tongue.  These  were  shown  by  microscopic  examination  to  be  not  epithelioma, 
the  only  epithelioma  being  along  the  left  border  and  in  the  center  of  the  tongue. 


Fig.  58. — Longitudinal  Section  of  Tongue  in  the  Median  Line,  Showing  Two 
Small  "Islands"  of  Epithelioma  in  its  Posterior  Portion.  Same  subject 
as  Fig.  57. 

9  99 


100 


ruMoRS   \\i>  Deformities  of  the  head 


scopic  examination  of  small  sections  of  tissue  may  be.  Such  sec- 
tions were  twice  removed  from  the  center  of  this  tongue,  and  were 
correctly  pronounced  to  be  not  epitheliomatous.  A  third  section 
was  then  taken  from  the  left  lateral  margin,  and  was  found  to  pre- 
sent the  usual  appearances  of  epithelioma. 

Treatment. — The  best  treatment  of  a  patien.1  who  has  an  epi- 
thelioma in  an  early  stage  is  a  complete  removal  of  the  tumor, 

together  with  a  reasonable 
margin  of  healthy  tissue  on  all 
sides  of  it  and  beneath  it. 
Just  how  wide  this  margin 
should  he  cannot  he  stated  by 
a  general  rule.  If  the  tissue 
is  lax  and  abundant,  it  is  well 
to  make  the  incision  one-third 
of  an  inch  away  from  the  vis- 
it" the 


Fig.  59. — Transverse  Section  of  the 
Tongue  through  the  Anterior  "Is- 
land" of  Epithelioma  Shown  in 
Fig.  58.  It  will  be  observed  that  the 
whole  of  this  epithelial  growth  was 
from  the  lateral  margin  of  the  tongue. 


ible  edge  of  the  tumor, 
surrounding  skin  is  less  flex- 


ible, or  if  the  tumor  is  so  situ- 
ated that  a  scar  will  be  very 
prominent,  one  is  perhaps  justi- 
fied in  removing  a  narrower 
zone  of  healthy  tissue  with  the  tumor.  This  is  more  likely  to  be 
the  case  if  the  growth  of  the  tumor  is  almost  wholly  upward,  and 
infiltration  has  not  yet  taken  place. 

When  the  tumor  has  been  removed,  hemorrhage  is  controlled 
by  pressure  or  ligation  of  vessels,  and  the  surgeon  must  consider 
the  best  manner  of  covering  the  defect.  In  many  cases  the  wound 
may  be  closed  by  direct  suture  if  the  surrounding  skin  is  loosened 
from  the  deep  fascia.  In  other  cases  a  plastic  operation,  or  skin 
grafting,  or  a  combination  of  the  two  methods,  will  give  the  best 
results. 

The  regional  lymph-glands  should  be  examined.  If  they  are 
palpably  enlarged  the  spaces  in  which  they  lie  should  be  thor- 
oughly freed  by  dissection  of  glands  and  the  connective  tissue  in 
which  they  lie.  This  requires  general  anesthesia.  Some  surgeons 
advocate  it  as  a  routine  measure  in  all  cases,  whether  the  glands 
are  palpable  or  not.  In  such  an  early  stage  of  the  disease  as  is 
shown  in  Figures  54  and  60   it  hardlv  seems  warrantable  to  add  so 


EPITHELIOMA 


101 


much  to  the  risk  of  operation,  when  the  prognosis  is  so  good  with- 
out the  more  extensive  dissection.  If  the  glands  are  palpably 
enlarged,  prognosis  is  much  more  grave,  but  is  still  sufficiently 
good  to  make  a  complete  removal  of  glands  and  tumor  desirable. 
Every  tumor  of  the  skin  which  is  removed  should  be  examine  I 
microscopically. 

The  removal  of  epithelioma  of  the  lower  lip  is  accomplished 
as  follows:  The  lower  lip  is  shaved  and  cleansed  thoroughly  with 
soap  and  hot  water.  The  teeth  are  brushed  and  the  mouth  rinsed 
with  a  dilute  antiseptic.  The  lip  is  wiped  with  cotton  wet  with 
a  stronger  antiseptic  solution.  An  assistant  then  seizes  the  lip  at 
its  right  and  left  ends,  between  his  thumb  and  fingers,  standing 
behind  the  patient  and  putting  the  thumbs  inside  the  patient's 
mouth.  This  compresses  the  inferior  coronary  and  inferior  labial 
arteries  and  absolutely  controls  hemorrhage.  The  operator  then 
injects  from  twenty  to  forty  minims  of  a  one  per  cent  solution  of 
cocain  along  the  lines  of  incision,   and  cuts   a  Y-shaped  section 


Fig.    60. — Epithelioma    of   Lower   Lip.     Duration   one   year.     Patient    ready   for 

operation. 


from  the  lip,  the  incisions  for  the  purpose  (Fig.  61)  passing- 
through  the  whole  thickness  of  the  lip.  They  start  in  the  free 
border  at  least  one-third  of  an  inch  from  the  visible  margin  of  the 
growth.  The  V  should  extend  well  down  on  the  chin.  This  re- 
duces the  amount  of  deformity  as  wTell  as  guards  against  recurrence. 
The  wound  is  sutured  with  fine  black  silk  (Fig.  62).  If  the 
external  stitches  include  all  of  the  tissues  except  the  mucous  mem- 


102 


TUMORS    AND    DEFORMITIES   <>F  THE   HEAD 


brane,  apposition  will  be  so  perfecl  thai  the  mucous  membrane 
need  nol  be  sutured.  This  saves  a  rather  difficult  extraction  of 
sutures  from  within  the  mouth.     A  narrow  strip  of  gauze  should 


Fig.  Gl. — Epithelioma  of  Lower  Lip,  Showing  the  Line  of  Incisions. 

be  placed  over  the  wound  and  tension  relieved  by  a  strip  of  adhe- 
sive plaster  from  one  side  of  the  chin  to  the  other.  One-third  of 
the  lower  lip  may  he  removed  with  the  certainty  that  no  perma- 


Fig.  62. — Epithelioma  of  Lower  Lip.     After  excision  of  the  V-shaped  piece,  the 
gap  in  the  lip  is  closed  by  sutures  which  need  not  penetrate  the  mucous  membrane. 

nent  deformity  will  result.  If  the  tumor  is  situated  very  near  the 
angle  of  the  mouth,  it  may  be  necessary  to  extend  the  incision 
outward  through  the  cheek  to  give  greater  freedom  to  the  rem- 
nant of  the  lower  lip. 


EPITHELIOMA  103 

Epithelioma  of  the  tongue  may  occur  upon  the  dorsum  of  the 
tongue,  or  along  the  edge,  or  in  the  vicinity  of  the  frenum.  As  I  he 
early  removal  of  this  tumor  has  a  favorable  prognosis,  it  is  ex- 
tremely important  that  it  should  he  recognized  before  the  growth 
is  extensive,  and  before  the  lymphatic  glands  in  the  neck  have 
become  involved.  Unfortunately  patients  are  indifferent  to  small 
sores  upon  the  tongue  until  they  give  rise  to  considerable  pain. 
The  saliva  soaks  off  any  discharge,  so  that  the  sore  has  not  the 
striking  appearance  of  an  epithelioma  of  the  skin  with  its  cover- 
ing of  crusts.  For  this  reason,  most  physicians  fail  to  recognize 
epithelioma  of  the  tongue  as  soon  as  they  should  do  so. 

The  disease  first  appears  in  one  of  three  ways :  There  may  be 
a  white,  wartlike  growth,  without  ulceration,  and  with  a  scarcely 
noticeable  induration  at  the  base.  Second,  there  may  be  a  flat, 
slightly  raised,  smooth,  red  tumor  which  feels  like  a  bit  of  gristle 
in  the  surface  of  the  tongue.  At  a  later  stage  this  will  ulcerate. 
Third,  an  old  area  of  leucoplakia  which  possibly  has  existed  for 
years  will  take  on  a  malignant  growth  in  some  portion,  showing 
distinct  elevation,  and  then  some  induration  at  the  base.  This, 
too,  will  ulcerate  later  (Figs.  57—59). 

If  an  epithelioma  of  the  tongue  is  recognized  at  an  early  stage, 
before  ulceration  sets  in,  the  resection  of  the  tumor  with  a  safe 
zone  of  healthy  tissue  around  it  is  a  thoroughly  safe  operation. 
Some  surgeons  advocate  the  removal  of  the  fascial  tissue  contain- 
ing lymph  glands  from  the  neck,  although  at  this  early  stage  the 
glands  which  are  removed  can  rarely  be  demonstrated  to  contain 
cancer  cells.  If  the  disease  is  allowed  to  progress  until  ulceration 
has  taken  place,  and  there  is  marked  infiltration  of  the  tongue, 
and  the  lymphatic  glands  of  the  neck  are  palpably  enlarged,  re- 
moval of  one-half,  or  even  the  whole,  tongue,  and  an  extensive  dis- 
section in  the  neck  gives  slight  hope  of  permanent  cure.  Radical 
cure,  under  such  circumstances,  is  achieved  in  probably  not  more 
than  twenty-five  per  cent  of  the  cases.  The  indication  is,  there- 
fore, strongly  in  favor  of  early  removal  at  a  time  when  the  opera- 
tion may  be  performed  under  cocain  if  necessary,  and  most  of  the 
tongue  may  be  preserved.  On  account  of  its  free  circulation  and 
great  flexibility  the  tongue  is  an  excellent  subject  for  plastic  work. 

Methods  of  Treatment  other  than  Excision. — Epithelioma  of 
the  face  may  be  removed  by  chemical  caustics  or  other  agencies 


104  Tl  MORS    V.ND    DEFORMITIES  OF  THE    HEAD 

capable  of  destroying  tissue  cells,  such  as  the  X-ray.  That  many 
eures  have  been  effected  l>v  these  means,  every  unprejudiced  ob- 
server readily  admits.  They  are  generally  considered  to  be  less 
certain  methods  of  removing  the  growth.  They  require  a  long 
period  to  effect  their  object,  and  evidence  is  lacking  to  show  that 
recurrence  is  less  likely  to  occur  when  a  tumor  has  been  destroyed 
by  caustics  than  when  it  has  been  removed  with  a  knife.  Indeed, 
from  what  Ave  know  of  the  structure  of  the  skin  and  of  the  nature 
of  tumor  growth,  it  is  probable  that  recurrence  is  less  likely  when 
a  /one  of  healthy  tissue  is  removed  with  the  tumor  than  when 
the  tumor  cells  are  killed  in  situ,  so  to  speak. 

Methods  other  than  excision  are  therefore  to  be  adopted  only 
when  the  patient  refuses  to  allow  the  removal  of  the  tumor  by 
means  of  the  knife.  One  of  the  best  caustics  to  employ  is-  a  one 
per  cent  solution  of  arsenious  acid  in  alcohol.  A  few  drops  of 
hydrochloric  acid  increase  its  solubility.  This  may  be  painted  on 
with  a  camel's-hair  brush  every  second  day.  This  is  a  cleaner 
method  of  application  than  the  usual  one  of  arsenic  paste. 

In  using  the  X-ray  for  the  destruction  of  an  epithelioma,  the 
surrounding  skin  should  be  protected,  and  the  length  of  exposure, 
distance  from  the  tube,  etc.,  should  be  carefully  noted  at  each 
treatment.  In  beginning  treatment  it  is  well  to  err  on  the  side 
of  safety,  so  that  the  exposure  should  be  brief,  and  three  days 
should  elapse  between  treatments.  Later,  when  the  full  effects  of 
the  X-ray  can  be  estimated,  treatments  may  be  increased  in  sever- 
ity and  in  frequency.  The  details  of  this  form  of  treatment  have 
been  frequently  published  in  magazines  and  monographs. 

Sarcoma. — Sarcoma  of  the  head,  while  not  very  common,  oc- 
curs with  sufficient  frequency  to  make  the  differential  diagnosis  be- 
tween it  and  benign  growths  of  great  importance.  The  diagnosis 
is  often  a  difficult  one  in  this  region  on  account  of  the  frequency 
here  of  sebaceous  and  dermoid  cysts  and  of  gummata  and  other 
inflammatory  lesions.  Two  essential  points  shown  by  a  malig- 
nant but  not  by  a  benign  tumor,  are  the  lack  of  a  distinct  bound- 
ary and  the  presence  of  enlarged  blood-vessels  in  the  vicinity  of 
the  tumor.  Both  of  these  signs  were  present  in  the  case  shown 
in  Figure  63.  This  tumor  had  been  growing  rapidly  for  some 
months,  but  without  pain  or  cerebral  symptoms.  It  had  been 
diagnosed  as  a  sebaceous  cyst  by  two  doctors,  and  an  immediate 


SA  I  ICO  MA 


wt 


office  operation  advised  and 
a  speedy  cure  promised.  An- 
other doctor  had  affirmed  that 
it  was  cancerous  and  that  its 
removal  would  prove  fatal. 
The  surgeon  in  whose  care 
the  patient  finally  placed 
herself  removed  a  section  of 
the  tumor  for  examination. 
Upon  learning  that  the  tumor 
was  not  sarcoma,  and  having 
found  it  to  be  encapsulated,  he 
later  removed  it  without  diffi- 
culty, but  with  so  great  a  loss 
of  blood  that  the  patient  did 
not  rally.  It  was  extradural, 
but  had  eroded  a  circular  area 
of  the  skull  about  two  inches 
in  diameter.    The  substance  of 

the  tumor  itself  was  on  gross  and  microscopic  examination  like  the 
tissue  of  a  rapidly  hypertrophying  thyroid  gland. 


Fig.  63. — Tumor  of  Head — Extradu- 
ral— Classified  on  Pathological 
Examination  as  an  Aberrant  Thy- 
roid. 


Fig.  64. — Angiosarcoma  of  the  Lower  Jaw  of  a  Colored  Girl,  Aged  Twenty- 
three.     The  tumor  had  been  noticed  for  one  month. 


100 


n.\im;s  and  deformities  of  the  head 


Sarcoma  of  the  face  is  far  less  common  than  epithelioma. 
Sometimes  a  small  and  apparently  innocent  tumor  of  the  skin  will 
prove  upon  microscopical  examination  to  be  sarcoma. 

Angiosarcoma  of  the  jaw  occurs,  and  has  a  marked  diagnostic 
importance  because  in  its  early  stages  (Fig.  64)  it  may  be  mis- 
taken for  the  spongy  condition  of  the  gums  due  to  scrofula.  The 
history  of  the  disease  and  the  general  condition  of  the  patient  will 
usually  suffice  for  a  correct  diagnosis.  In  doubtful  cases  a  micro- 
scopical examination  of  a  fragment  of  the  tumor  should  be  made. 
Attention  to  the  diet,  and  the  use  of  an  astringent  mouth  wash 
Avhich  will  speedily  improve  scrofulous  gums  will,  of  course,  have 
no  effect  upon  the  development  of  a  sarcoma. 

Parotid  Tumors. — In  the  region  of  the  angle  of  the  jaw  ma- 
lignant tumors  of  varied  histological  structure  arise  in  connection 
with  the  parotid  gland:  carcinoma,  sarcoma,  chondroma,  myxoma, 


Fig.  05. — Tumor  of  Parotid  Gland,  said  to  have  Existed  Ten  or  Twelve  Years. 
The  skin  was  not  attached,  and  the  tumor  was  movable  in  all  directions. 


CANCER   OF  TONSIL  1.07 

and  a  combination  in  one  tumor  of  the  various  structures  which 
these  names  imply,  may  develop  in  this  situation  and  give  rise  to 
a  rounded,  hard  mass,  usually  composed  of  more  than  one  lobule, 
which  grows  slowly  or  rapidly  and  often  reaches  the  size  of  a  small 
egg  before  the  patient  seeks  surgical  aid  (Fig.  65).  Such  a  tumor, 
like  malignant  tumors  of  a  parenchymatous  nature  elsewhere  in 
the  body,  is  most  often  seen  in  middle  life  or  later.  If  the  condi- 
tions warrant  it,  no  time  should  be  lost  after  the  diagnosis  is  made 
in  accomplishing  its  thorough  removal.  As  the  tumor  springs 
from  the  gland  it  is  closely  attached  to  it,  but  is  movable  with 
the  gland  upon  the  skin  and  deeper  tissues.  As  it  grows  it  infil- 
trates the  surrounding  tissues  so  that  this  mobility  is  soon  lost. 
It  may  be  distinguished  from  an  inflammatory  process  by  the  his- 
tory of  its  slow  development,  by  its  hardness,  and  by  its  situation 
in  the  parotid.  It  is  most  likely  to  be  confounded  with  tubercu- 
losis or  syphilis  of  the  cervical  lymphatic  glands.  These  are  usu- 
ally situated  below  the  angle  of  the  jaw,  but  they  may  also  extend 
above  it.  In  affections  of  the  lymphatic  glands  careful  exami- 
nation will  almost  always  show  that  two  or  more  distinct  glands  are 
involved;  whereas  if  a  malignant  tumor  has  nodules  they  can  be 
shown  to  be  connected,  being  invariably  part  of  the  same  growth, 
except,  of  course,  in  case  of  secondary  lymphatic  involvement. 
Furthermore,  tubercular  and  syphilitic  glands  which  have  attained 
any  considerable  size  fall  to  pieces  internally  so  that  fluctuation 
can  usually  be  made  out  in  them. 

Cancer  of  Tonsil. — Tumors  of  the  tonsil  of  a  malignant 
character  are  on  the  border-line  histologically  between  carcinoma 
and  sarcoma.  They  may  he  easily  mistaken  for  a  chronic  hyper- 
trophy of  the  tonsil,  and  if  there  is  the  slightest  question  a  large 
section  of  the  tumor  should  be  taken  for  examination  by  a  pathol- 
ogist. Even  then  the  diagnosis  may  not  be  an  absolute  one,  and 
the  decision  between  the  risk  of  allowing  the  tumor  to  remain  and 
the  risk  of  an  operation  for  its  radical  removal  is  one  of  the  most 
difficult  in  surgery.  If  a  presumably  hypertrophied  tonsil  is  am- 
putated by  means  of  the  tonsillotome  and  subsequently  recurs, 
this  fact,  even  more  than  the  result  of  histological  examination, 
will  incline  the  surgeon  to  perform  a  more  radical  operation  for 
removal  of  the  tumor.  These  tumors  affect  the  deeper  structures, 
and  do  not  give  rise  to  ulceration  until  a  late  stage  is  reached. 


10S  TUMORS    Wl»    DEFORMITIES   OF  THE    HEAD 

Their  treatment  is  beyond   the  range  of  minor  surgery,  but  the 
subject  is  mentioned  here  on  account  of  diagnostic  importance. 


ACQUIRED   DEFORMITIES 

Cicatrices. — Cicatricial  contractions  in  the  vicinity  of  the 
eye  may  so  pull  upon  the  lids  as  to  cause  their  partial  eversion  or 
prevent  the  tears  from  flowing  through  the  tear-duct  in  a  natural 
manner.  To  relieve  this  in  certain  cases  plastic  operations  may 
be  performed  with  more  or  less  success,  and  even  where  the  eyelid 
bas  been  partially  destroyed  a  substitute  may  be  found  in  a  flap 
of  skin  taken  from  die  adjacent  skin. 

Cicatricial  deformity  of  the  lip  from  a  burn  of  the  neck  is 
shown  in  Figure  ST  on  page  148. 

Nasal  Deformities. — Deformities  of  the  nose  are  among 
the  commonest  disfigurements.  When  hereditary  syphilis  attacks 
the  nose  of  an  infant  or  child,  or  contracted  syphilis  the  nose 
of  an  adult,  it  often  destroys  the  cartilage  to  such  an  extent 
that  there  is  a  hollowing  out  where  normally  the  bones  and 
cartilage  should  be  prominent.  The  result  is  often  called  a 
saddle-nose. 

Treatment. — Numerous  attempts  have  been  made  to  cure 
these  deformities  in  later  life  by  inserting  some  rigid  substance  to 
make  good  the  lack  of  bony  support.  Any  support  which  is  fixed 
to  the  bones  of  the  face  will  soon  fail,  because  of  the  softening 
of  the  bones  upon  which  it  rests,  and  its  removal  will  be  necessary. 
A  far  better  plan,  therefore,  when  the  tip  of  the  nose  is  not  de- 
stroyed, is  to  insert  beneath  the  skin  a  boat-shaped  piece  of  cellu- 
loid, the  upper  surface  of  which  is  straight  or  slightly  rounded 
while  the  under  surface  is  shaped  to  fit  the  sunken  bridge  of  the 
nose.  If  the  incision  made  at  the  side  of  the  nose  for  the  insertion 
of  the  celluloid  is  a  small  one  and  made  obliquely  through  the  skin, 
the  resulting  scar  will  be  quite  invisible.  Necrosis  of  bone  will  not 
be  produced  as  the  periosteum  is  not  disturbed.  Before  the  cellu- 
loid is  inserted,  a  bed  is  made  for  its  reception  by  separating  the 
skin  from  the  cartilage  with  an  appropriate  instrument,  a  favorite 
one  being  made  like  a  minute  ax  upon  a  very  long  handle.  The 
bed  should  be  so  prepared  that  the  celluloid  may  lie  in  it  easily, 
and  no  attempt  should  be  made  to  hold  it  in  position  by  a  bandage 


DEVIATION   OF   THE   SEPTUM   OF   THE   NOSE 


109 


or  plaster.  If  the  result  is  to  be  satisfactory,  the  support  must  rcsl 
easily  in  the  cavity  prepared  for  it. 

Deviation  of  the  Septum  of  the  Nose.  — The  septum  of 
the  nose  may  be  deviated  to  one  side,  usually  as  a  result  of  trau- 
matism.    One  air-passage  may  be  closed  thereby. 

Treatment. — A  number  of  operations  have  been  proposed  to 
establish  free  passage  of  air  through  both  nasal  fossa?.  The  sim- 
plest of  all  is  to  punch  out  a  large  opening  in  the  septum  at  its 
most  projecting  point.  The  practical  result  of  this  is  good,  but  it 
is  a  permanent  deformity,  and  as  such  has  not  appealed  to  the 
minds  of  either  surgeons  or  patients. 

Of  the  many  operations  which  have  been  devised  to  straighten 
the  septum,  two  may  be  mentioned  as  comparatively  simple  in 
technic,  and  likely  to  yield  a  good  result.  A  tongue-shaped  flap 
of  the  whole  thickness  of  the  septum  may  be  cut  from  the  convex 
side.     While  it  is  still  attached  posteriorly,  it  should  be  pushed 


Fig.  66. — Diagram  of  the  Septum  of  the  Nose,  Showing  the  Portion  Nece&sary 
to   Resect  Submtjcously  to  Cure   Deviation  of  the   Septum. 


through  the  opening  in  the  septum  until  it  lies  in  the  other  nos- 
tril. A  hollow  rubber  cone  may  be  placed  in  the  nostril  to  prevent 
the  flap  from  resuming  its  original  position  until  healing  has  taken 
place. 

A    newer    method    is    submucous    excision.      Anesthesia    and 
ischemia  are  produced  by  the  surface  application  of  cocain  and 


IK)  TUMORS   AND   DEFORMITIES   OF   THE    HEAD 

adrenalin  for  twenty  minutes  or  more.  An  incision  is  made  on 
the  convex  side  about  a  third  of  an  inch  posterior  to  the  junction 
of  skin  and  mucous  membrane.  This  incision  extends  through  the 
perichondrium.  Through  this  incision  the  mucous  membrane  and 
perichondrium  arc  peeled  from  the  convex  surface  of  the  septum. 
The  anterior  incision  is  next  carried  through  the  cartilage  of  the 
septum,  and  the  perichondrium  is  peeled  from  the  concave,  sur- 
face of  the  septum.  The  denuded  portion  of  cartilage  is  then  ex- 
cised with  a  special  knife  and  scissors.  It  is  usually  necessary  to 
excise  with  a  small  chisel  a  portion  of  the  nasal  spine  of  the  supe- 
rior maxilla,  and  a  portion  of  the  vomer  (Fig.  GO).  In  any  event 
the  resection  should  be  continued  until  the  septum  hangs  straight 
in  the  middle  line.  The  incision  is  closed  with  two  or  three 
sutures.  AO  after  treatment  is  required;  or  a  little  gauze  may 
be  kept  in  each  nostril  for  forty-eight  hours.  It  is  important  to 
preserve  both  layers  of  perichondrium,  so  that  a  certain  amount 
of  rigidity  may  be  retained,  and  in  order  to  avoid  subsequent  per- 
foration of  the  septum  through  atrophy. 

Elongation  of  the  Uvula. — A  catarrh  of  the  naso-pharynx 
sometimes  leads  to  enlargement  and  elongation  of  the  uvula.  Such 
elongation  is  a  common  accompaniment  of  acute  inflammation  of 
the  throat,  and  disappears  as  soon  as  the  inflammation  subsides. 
2sTo  treatment  of  the  uvula  itself  is  necessary  in  such  cases.  It  is 
quite  another  matter  Avhen  the  uvula  is  chronically  so  elongated 
that  its  tip  rests  constantly  on  the  base  of  the  tongue  or  even 
reaches  to  the  epiglottis,  causing  the  patient  to  gag  and  cough, 
particularly  when  he  lies  upon  his  back.  The  possibility  that  a 
persistent  dry  cough  is  due  solely  to  uvular  irritation  should  be 
borne  in  mind. 

Inspection  of  the  throat  will  show  at  once  whether  the 
uvula  is  long  enough  to  cause  irritation.  If  acute  inflamma- 
tion is  present  one  should,  of  course,  wait  until  this  has  passed 
over  before  condoning  the  uvula,  as  the  elongation  may  be  tem- 
porary. 

Treatment. — When  a  uvula  is  elongated  and  the  cause  of 
irritative  symptoms,  it  should  be  shortened  by  appropriate  treat- 
ment. This  means  first  of  all  attention  to  the  general  conditions 
of  health  of  which  the  relaxation  of  the  uvula  may  be  only  one 
manifestation.      Such  general  causes  are  indigestion  or  constipa- 


ELONGATION   OF   THE   UVULA 


111 


tion,  too  much  tobacco  or  alcohol,  over-exertion,  bad  air  at  wor] 
or  during  sleep,  breathing  through  the  mouth,  etc. 

Astringent  gargles  and  sprays,  or  the  application  directly  to 
the  uvula  of  stronger  preparations  than  the  patient  should  handle 
himself,  will  sometimes  result  in  a  cure.  Tannic  acid,  alum,  and 
the  salts  of  silver  are  remedies  worth  trying. 

If  local  remedies  and  attention  to  the  general  health  fail  to 
shorten  the  uvula  sufficiently  to  cause  the  disappearance  of  symp- 


Fig.  67. — Scissors  for  Ampu 


the  Uvo 


toms,  a  portion  of  the  little  organ  should  he  removed.  This  opera- 
tion is  a  simple  one,  hut  it  is  desirable  that  the  excision  should  be 
exact,  since  the  removal  of  too  much  or  too  little  may  subject  the 
operator  to  a  good  deal  of  criticism,  especially  if  some  symptoms 
persist.  The  uvula  should  be  anesthetized  by  the  application  of 
one  per  cent  cocain  on  a  cotton  swab  to  its  anterior  and  posterior 


112  TUMORS  AND   DEFORMITIES  OF  THE  HEAD 

surfaces.  The  tip  of  the  uvula  should  then  be  seized  with  niouse- 
tooth  forceps  and  drawn  somewhal  forward.  A  sufficient  part  of 
the  organ  is  then  to  be  cu1  away  with  curved  scissors.  The  part 
removed  should  extend  higher  posteriorly  than  in  front.  By  this 
means  the  blunt  appearance  of  the  inula  is  avoided,  and  the 
wound  is  placed  on  the  posterior  surface  and  so  is  less  affected  by 
swallowing.  Unless  the  uvula  is  held  by  forceps  during  the  section 
il  is  likely  to  slip  from  the  scissors.  A  special  instrument  has  been 
made  for  the  purpose  which  combines  the  action  of  the  forceps 
and  scissors.  It  is  called  an  uvula  scissors  (Fig.  67).  If  hemor- 
rhage follows,  it  is  readily  controlled  by  pressure  with  a  swab  we1 
with  a  solution  of  adrenalin,  or  peroxid  of  hydrogen,  or  one  of 
the  other  styptics. 

No  after-treatment  is  required  other  than  the  use  of  iced  Do- 
bell's  solution  as  a  gargle,  or  some  similar  alkaline  solution,  and 
the  avoidance  of  coarse  or  seasoned  articles  of  diet  for  a  few  days. 

CONGENITAL   DEFORMITIES 

Harelip  and  Cleft  Palate  are  common  congenital  deformi- 
ties. There  may  be  either  one  or  two  clefts  of  the  lip  and  anterior 
portion  of  the  mouth,  hut  the  posterior  portion  of  the  hard  palate 
and  the  soft  palate  develop  from  right  and  left  halves,  so  that  a 
cleft  due  to  imperfect  development  is  invariably  single.  If  the 
harelip  is  double  its  central  portion  is  connected  with  the  inter- 
maxillary bone  and  is  attached  to  the  septum  of  the  nose.  This 
deformity  may  be  so  extreme  that  even  a  successful  operation  pro- 
duces a  most  unsatisfactory  result.  The  opening  may  be  closed, 
but  the  scar  and  disfigurement  which  persist  are  most  unsightly. 
If,  on  the  other  hand,  the  development  of  tissue  both  of  the  central 
portion  and  margins  of  the  clefts  has  been  abundant,  it  is  possible 
to  produce  something  like  a  normal  appearance,  even  though  the 
clefts  open  into  the  anterior  nares.  If  the  cleft  is  unilateral  and 
exists  in  the  lip  only  (Fig.  68),  a  perfect  result  may  be  obtained, 
so  that  it  is  scarcely  possible  in  after-years  to  perceive  that  a  hare- 
lip existed.  The  time  for  operation  has  been  the  occasion  of  much 
dispute  among  surgeons,  but  it  is  now  pretty  generally  admitted 
that  a  cleft  palate  should  not  be  operated  upon  until  the  child  is 
six  or  eight  years  old,  whereas  a  better  result  is  obtained  if  a 


HARELIP   AND   CLEFT   LA LATH 


113 


harelip  is  operated  upon  in  early  infancy,  say  from  the  third  to 
the  sixth  month,  or. even  earlier  if  the  cleft  in  the  lip  interferes 
with  the  proper  nutrition  of  the  child  or  causes  deviation  of  the 
nasal  septum  (Fig.  69).  Sometimes,  when  the  child  cannot  nurse 
from  the  breast  it  may  take  milk  from  the  bottle,  or,  if  not,  life 
may  still  be  preserved  by  pouring  milk  into  its  mouth   from  a 


Fig.  68. — Harelip,  the   Cleft  not  Ex-  Fig.  69. — Harelip,  the  Cleft  Exterixg 

tering  the  Nostril.     The  vermilion  the  Nostril.     Note  the  deviation  of 

of  the  lip  extends  into  the  cleft,  but  is  the  septum,  even  in  this  comparatively 

much  narrower  there.  simple  case. 


teaspoon,  or  the  feeding  may  be  accomplished  by  the  passage  of  a 
soft  rubber  catheter  into  the  esophagus. 

Treatment. — In  operating  for  harelip  it  is  of  the  first  im- 
portance that  the  vermilion  border  be  accurately  approximated, 
and,  secondly,  that  a  slight  excess  of  tissue  at  the  suture-line  be 
provided ;  otherwise  the  contraction  which  follows  in  every  scar 
will  draw  the  lip  upward  at  the  line  of  suture  and  a  slight  notch 
will  result.  To  overcome  this,  it  has  been  found  best  to  make  an 
oblique  incision  through  the  vermilion  portion  of  the  lip  and  to 
leave  a  little  fulness  at  this  point.  If  the  power  of  contraction 
is  overestimated  it  is  very  easy  to  reduce  this  excess  at  a  later 
period  of  life.  The  edges  of  the  cleft  must  be  pared  so  that  they 
shall  be  even,  and  enough  tissue  must  be  removed  to  make  the 
edges  to  be  sutured  equal  in  thickness  to  the  rest  of  the  lip. 

The  suturing  is  very  important.  Fine  black  silk  is  the  best 
material  for  the  purpose.      There  may  be  a  number  of  stitches 


114  TUMORS   AND   DEFORMITIES   OF  THE   HEAD 

which  approximate  separately  the  mucous  membrane  and  the  skin. 
Or  fewer  stitches  may  be  employed  and  passed  through  the  whole 
thickness,  or  nearly  the  whole  thickness,  of  the  lip.  In  any  case 
the  strain  should  be  evenly  distributed  upon  the  stitches.  Some 
operators  employ  one  or  two  additional  stitches  set  Avell  back  from 
the  wound,  in  order  to  take  the  strain  off  the  suture-line.  This 
can.  however,  be  accomplished  with  less  disfigurement  by  placing 
a  narrow  strip  of  strong  gauze,  such  as  bolting  silk,  across  the  lip 
from  cheek  to  cheek,  fastening  its  ends  to  the  cheeks  by  collodion. 
Another  method  is  to  carry  two  strips  of  adhesive  plaster  from  the 
cheeks  to  the  forehead.  These  two  strips  make  an  X,  crossing  over 
the  bridge  of  the  nose,  and  fully  relieve  tension  upon  the  upper  lip. 

The  stitches  should  be  removed  as  early  as  possible,  say  in 
three  or  five  days,  in  order  to  avoid  a  prominent  scar,  but  the  strain 
on  the  lip  must  be  prevented  for  a  longer  period  by  one  of  the 
methods  mentioned.  In  infants  operation  for  simple  harelip  may 
be  done  without  any  anesthetic,  or  with  a  very  little  chloroform. 

Cleft  of  the  Lower  Lip. — A  rare  deformity,  and  one  which  is 
always  single  in  the  median  line,  is  the  cleft  of  the  lower  lip  (Fig, 


Fig.  70. — Congenital  Cleft  of  Lower  Lip. 

TO).     It  is  easily  cured  by  a  V-shaped  excision  of  the  cleft  fol- 
lowed by  suture  (p.  101). 

Treatment  for  Cleft  Palate. — If  the  cleft  in  the  palate 
involves  only  the  soft  palate,  the  operation  for  its  relief  is  very 


TONGUE-TIE  115 

simple.  It  consists  in  paring  the  edges  of  the  cleft  and  carefully 
approximating  them  with  many  fine  black  silk  sutures.  If  the 
cleft  extends  also  into  the  bony  portion  and  is  not  too  wide,  it 
may  be  closed  by  suture  of  the  mucous  membrane  alone.  To  make 
this  possible,  however,  it  is  necessary  to  make  preliminary  inci- 
sions about  half  an  inch  from  the  cleft  on  either  side  and  separate 
the  strips  of  mucous  membrane  from  the  hard  palate.  These  two 
strips,  right  and  left,  may  then  be  sutured  in  the  middle  without 
great  tension. 

To  close  a  larger  cleft  a  strip  of  bone  and  mucous  membrane 
may  be  chiseled  from  either  side  and  sutured  together  in  the  mid- 
dle. If  this  operation  is  successful,  two  small  clefts  remain  which 
can  be  closed  by  subsequent  operation.  The  details  of  these  opera- 
tions will  be  found  in  books  on  major  surgery.  Complete  anes- 
thesia is  necessary. 

If  it  is  decided  to  wait  some  years  before  operating  for  cleft 
palate,  a  plate  of  rubber  should  be  fitted  and  worn.  This  can  be 
done  as  soon  as  the  child  has  double  teeth  to  which  the  plate  can 
be  fastened — generally  at  two  years  of  age.  Such  a  plate  facili- 
tates swallowing  and  is  a  great  help  to  the  child  in  its  efforts  to 
talk. 

Thick  Lips. — Persons  with  very  thick  lips  sometimes  become 
dissatisfied  with  their  appearance  and  seek  surgical  aid.  An  im- 
provement can  be  accomplished  by  the  removal  of  an  elliptical 
shaped  piece,  the  incisions  for  which  should  lie  fully  within  the 
vermilion  portion  of  the  lip  and  should  run  on  either  side  to  a 
very  fine  point,  in  order  to  produce  a  smooth  appearance. 

Tongue-tie. — Parents  often  think  their  child's  tongue  is  tied 

if  he  does  not  learn  to  talk  as  soon  as  the  average  child.     If  the 

frenum  of  the  tongue  is  very  short,  it  will  pull  upon  the  tip  of  the 

tongue  and  produce  a  cleft  in  the  tip  when  an  attempt  is  made  to 

extend  the   tongue.     Even  less   marked  shortening  may  have  an 

effect  upon  the  pronunciation  of  certain  words,  favoring  bad  habits 

of  speech,  or  possibly  subjecting  the  child  to  ridicule.     Therefore,  if 

this  deformity  exists  even  to  a  moderate  degree,  the  tongue  should 

be  lifted  and  the  frenum  snipped  with  scissors.    The  reverse  end  of 

a  grooved  director,  is  often  made  with  a  notch  for  this  purpose. 

Backwardness  in  acquiring  speech  is  generally  dependent  on  other 

causes ;  but  the  extra  attention  given  to  an  older  child's  efforts  to 
10 


110 


TUMORS  AXD   DEFORMITIES  OF   THE    HEAD 


speak,  following  this  operation,  sometimes  leads  to  an  improvement 
which  is  quite  astonishing. 

Deformities  of  the  Ear. — The  lobe  of  the  car  may  be  cleft, 
giving  the  appearance  shown  in  Figure  71.  A  much  commoner 
deformity  is  a  reduplication  of  some  portion  of  the  auricle,  an 
extreme  degree  of  which  is  shown  in  Figure  72.     These  supple- 


Fig.  71. 


-Congenita!,  Cleft  of  Lobe 
of  Auricle. 


Fig.  72. — Congenital  Deformity  of 
Ear. 


mentary  knobs  of  cartilage  may  or  may  not  be  closely  attached  to 
the  normal  cartilage.  Sinuses  in  front  of  the  tragus  are  spoken  of 
on  page  76. 

Many  of  the  deformities  of  the  auricle  may  he  perfectly  reme- 
died by  a  well-planned  plastic  operation.  In  closing  a  cleft,  con- 
genital or  acquired,  it  is  well  to  remember  that  the  essential  tissue 
to  be  sutured  is  the  cartilage.  When  the  incisions  have  been  made 
in  such  a  way  that  the  edges  of  the  cartilage  come  easily  together, 
there  will  be  no  trouble  in  suturing  the  skin.  The  first  step  is  to 
reflect  the  skin  from  the  perichondrium  on  all  sides  for  a  short 
distance,  but  not  to  cut  away  any  skin  until  the  deep  sutures  have 
been  inserted  in  the  cartilage.  Pieces  of  adhesive  plaster  affixed  to 
the  ear  on  either  side  of  the  wound,  and  laeed  or  sewed  together,  will 
relieve  tension  of  the  sutures. 


SECTION  II 
AFFECTIONS   OF    THE   NECK 


CHAPTER    IV 
INJURIES    AND    INFLAMMATIONS    OF    THE    NECK 

Contusions. — Contusions  of  the  neck,  if  serious,  are  so  be- 
cause of  the  injury  to  the  deeper  structures.  They  are  usually  the 
result  of  accidental  or  attempted  strangling.  The  skin  of  the  neck 
is  tough  and  freely  movable,  and  if  it  is  pressed  against  any  un- 
derlying bone,  it  may  escape  injury,  even  though  some  deeper 
structure  such  as  the  hyoid  bone  or  larynx  be  broken.  An  example 
of  this  is  seen  in  cases  of  wheel  injury.  The  wheel  of  a  vehicle, 
especially  if  rubber-tired,  may  pass  over  the  neck  and  even  break 
one  or  more  of  the  vertebra?  without  leaving  any  mark  externally. 

Foreign  Bodies. — A  foreign  body,  such  as  a  morsel  of  food 
or  some  harder  substance,  may  lodge  in  the  larynx,  trachea,  or 
esophagus.  (For  foreign  bodies  in  mouth  and  pharynx  see  page 
12.)  The  symptoms  vary  all  the  way  from  a  slight  irritation 
and  discomfort  on  swallowing,  to  complete  strangulation  and  in- 
tense pain,  depending  on  the  shape  and  characteristics  of  the  for- 
eign body  and  the  particular  position  which  it  occupies. 

Treatment. — Even  when  the  symptoms  are  not  alarming  the 
foreign  body  should  be  removed  as  promptly  as  possible,  in  order 
to  save  the  patient  from  the  inflammation  which  is  likely  to  follow 
its  presence,  and  which  may  by  its  swelling  completely  occlude 
the  air-passages.  The  patient's  efforts — coughing,  gagging,  and 
vomiting — may  expel  the  foreign  body,  or  it  may  be  extracted  by 
a  finger  passed  well  down  the  throat.  If  these  simpler  means  do 
not  suffice,  the  pharynx  and  larynx  should  be  inspected  with  a 
laryngeal  mirror  in  a  good  light,  and  the  foreign  body  extracted 
with  forceps.  If  the  patient  lies  on  his  back,  with  the  head  lower 
than  the   shoulders,   extraction  is   facilitated.      A  child  may  be 

117 


118  INJURIES  AND   INFLAMMATIONS  OF  THE  NECK 

turned  upside  down  in  an  effort  to  shake  out  the  foreign  body,  but 
only  for  a  few  moments.  If  respiration  is  seriously  interfered 
with  and  does  not  improve,  tracheotomy  is  indicated  (p.   L19). 

If  the  foreign  body  lias  entered  the  esophagus,  it  is  likely  to 
be  arrested  by  the  projection  of  the  cricoid  cartilage.  Tn  this  case 
it  may  still  be  extracted  by  forceps  introduced  through  the  mouth. 
If  it  is  of  such  a  nature  thai  ii  is  safe  to  allow  it  to  enter  the 
stomach,  the  patieni  should  try  to  crowd  it  forward  by  swallowing 
pultaceous  material,  such  as  well  chewed  bread.  If  the  foreign 
body  passes  the  cricoid  it  may  he  arrested  at  the  cardiac  orifice  of 
the  stomach.  This  has  happened  a  number  of  times  when  artificial 
teeth  have  been  swallowed.  This  condition  will  usually  require  a 
gastrotomy.  Time  may  be  taken  for  this,  however,  as  the  imme- 
diate distress  ends  with  the  passage  of  the  foreign  body  to  the 
lower  portion  of  the  esophagus. 

If  the  foreign  body  is  in  the  trachea  or  still  lower  in  one  of 
the  bronchi,  it  may  be  extracted  through  the  natural  passages 
through  an  opening  made  in  the  trachea  (tracheotomy,  see  p.  110), 
or  through  an  opening  made  directly  into  the  bronchus.  This  last 
will,  of  course,  not  be  attempted  unless  the  body  has  been  exactly 
located  by  means  of  the  X-ray.  It  will  always  remain  one  of  the 
rare  major  operations,  the  details  of  which  need  not  be  here  dis- 
cussed. After  the  foreign  body  has  been  removed,  the  patient 
should  gargle  with  normal  saline  solution,  or  use  an  alkaline  throat 
spray  (Dobell's  solution,  grycothymolin,  etc.). 

Wounds. — Wounds  of  the  neck,  especially  stab-wounds,  are 
relatively  common.  Their  interest,  too,  centers  in  the  injury  to 
the  deep  structures  which  may  coexist.  The  jugular  vein  may  be 
opened  by  a  stab-wound  or  by  a  cut,  as  with  a  razor.  Edema  of 
the  lax  tissues  may  speedily  become  distressing.  Death  from  hem- 
orrhage is  easily  possible.  Attempts  at  suicide  with  a  razor  often 
extend  no  deeper  than  the  jugular  vein,  although  there  are  in- 
stances in  which  an  individual  has  succeeded  in  dividing  most  of 
the  structures  of  the  neck  as  far  back  as  the  vertebra?.  A  cut,  even 
though  much  less  extensive,  may  open  the  air-jDassages,  usually 
between  the  hyoid  bone  and  the  thyroid  cartilage. 

Treatment. — Experience  has  shown  that  an  incised  vein  may 
be  sutured  and  its  continuity  restored,  but  it  is  scarcely  worth 
while  to  attempt  this  with  the  external  jugular,  as  interruption  of 


WOUNDS  1J9 

its  blood  current  has  no  significance.  In  general  the  decision 
should  be  to  ligate  all  the  large  vessels,  to  suture  with  catgut  any 
opening  into  the  air-passages,  and  to  provide  for  the  subsequent 
performance  of  tracheotomy  should  the  breathing  become  difficult 
through  swelling  of  the  larynx.  These  steps  may  all  be  performed 
under  the  influence  of  a  local  anesthetic  unless  the  patient,  very 
likely  insane,  refuses  to  remain  quiet. 

It  is  better  not  to  trust  to  pressure  to  control  hemorrhage  ex- 
cept in  the  most  superficial  wounds.  Pressure  may  stop  the  flow  of 
■blood  at  the  surface,  while  allowing  it  to  continue  in  the  deeper 
planes  of  tissue.  This  is  especially  true  in  the  case  of  irregular 
or 'punctured  wounds,  which  should  be  immediately  explored  to 
their  depths,  even  though  it  is  necessary  to  enlarge  the  wound  in 
the  skin.  Veins  as  well  as  arteries  should  be  ligated  with  fine 
catgut. 

Wounds  of  the  Esophagus. — A  stab-wound  of  the  neck,  without 
giving  rise  to  serious  symptoms,  may  penetrate  the  esophagus. 
Under  such  circumstances  there  will  be  a  slight  mucous  discharge 
to  which  may  be  added  milk,  water,  etc.,  when  the  patient  swal- 
lows these  fluids.  Such  a  wound,  if  it  has  good  drainage,  will 
generally  close  spontaneously  in  the  course  of  two  or  three  weeks ; 
but  one  should  be  on  his  guard  against  infiltration  of  the  deeper 
tissues  or  a  burrowing  of  pus  and  food  along  some  fascial  plane. 
If  necessary  the  external  wound  must  be  enlarged  to  afford  free 
drainage. 

If  the  opening  into  the  esophagus  cannot  be  satisfactorily 
sutured,  a  soft  rubber  tube  should  be  passed  into  the  lower  por- 
tion, through  which  the  patient  can  be  fed  temporarily  until  the 
wound  has  time  to  close  by  granulation,  or  permanently,  if  the  loss 
of  the  wall  of  the  esophagus  is  permanent. 

Tracheotomy. — Tracheotomy  performed  upon  a  normal  adult 
is  a  simple  operation.  A  vertical  incision  is  made  in  the  median 
line  from  the  cricoid  cartilage  downward  for  a  distance  of  an 
inch  or  more.  This  wound  is  deepened  until  the  surface  of  the 
trachea  has  been  bared  in  the  median  line  for  about  an  inch.  A 
scalpel  is  then  passed  through  the  anterior  wall  of  the  trachea. 
The  sides  of  the  incision  arc  separated  by  means  of  sharp  hooks 
or  an  especially  devised  dilator,  and  the  tracheotomy  tube  is  in- 
serted.    The  whole  procedure  may  be  performed  without  an  assist- 


120  INJURIES   AND    INFLAMMATIONS   OF  THE    NECK 

ant,  and  in  case  of  need  an  opening  has  been  made  with  a  jack- 
knife  and  death  from  strangulation  thus  averted.  In  an  infant, 
struggling  for  air  and  violently  moving  its  larynx  up  and  down, 
the  operation  is  far  more  difficult.  The  principles  arc  the  same, 
but  the  neck  is  so  shorl  that  exposure  of  the  trachea  for  a  sufficient 
distance  and  its  division  in  the  median  line  are  by  no  means  easy. 
In  adults,  under  circumstances  in  which  an  emergency  opera- 
tion is  necessary,  the  distance  from  the  skin  to  the  trachea  is  often 
greatly  increased  by  edema,  extravasation  of  blood,  and  venous 
congestion. 

The  instruments  which  are  essential  for  this  operation  are  a 
dissecting  and  mouse-tooth  forceps,  scalpel,  scissors,  artery  clamps, 
small  sharp  and  blunt  retractors,  a  curved  dressing  forceps  or 
a  specially  constructed  tracheal  dilator,  and  a  tracheotomy  tube 
(Fig.  73).  The  patient  lies  upon  his  back  with  the  neck  fully 
extended  over  a  hard  pillow  or  sandbag.  An  incision  is  made  in 
the  median  line  from  the  cricoid  cartilage  downward  for  an  inch 
and  a  half.  Veins  as  they  appear  should  be  divided  between 
clamps,  or  clamped  as  they  are  cut,  until  the  trachea  is  reached. 
The  isthmus  of  the  thyroid  should  be  drawn  upward.  If  time  per- 
mits, all  hemorrhage  should  be  controlled  before  the  trachea  is 
opened.  This  is  done  by  a  median  vertical  incision  for  a  distance 
of  three-quarters  of  an  inch.  The  walls  of  the  trachea  are  held 
apart  by  two  narrow  blunt  retractors  or  by  the  tracheal  dilator. 
Mucus  or  a  possible  foreign  body  is  sponged  away  or  removed  by 
means  of  a  curved  dressing  forceps,  and  the  tracheotomy  tube  is 
inserted.  The  wound  in  the  soft  parts,  if  unnecessarily  large, 
should  be  partly  closed  by  suture.  A  flat  collar  of  gauze,  impreg- 
nated with  some  antiseptic,  should  be  placed  between  the  shield 
of  the  tube  and  the  wound,  while  the  tube  itself  is  held  in  position 
by  two  tapes  tied  at  the  back  of  the  neck.  A  moist  sponge  should 
be  kept  over  the  mouth  of  the  tube  in  order  to  keep  the  inhaled 
air  warm  and  moist. 

Upon  the  care  of  a  tracheotomy  tube  depends  in  no  small  meas- 
ure the  early  cure  of  the  patient.  Mucus  may  be  removed  from 
the  tube  by  a  small  wisp  of  wet  cotton  on  a  bent  probe.  If  the 
tube  is  a  single  one,  it  should  be  removed  and  cleaned  at  least  once 
a  day.  The  wound  should  be  frequently  cleansed.  Only  the  mild- 
est antiseptics  are  permissible  in  such  a  situation.     A  double  tube, 


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121 


122  INJURIES    AM)   INFLAMMATIONS  OF  THE  NECK 

while  leaving  Less  space  for  the  air,  has  the  advantage  that  the 
inner  tube  can  be  removed  a1  any  time  without  disturbing  the 
wound,  and  it  can  always  be  replaced  without  difficulty.  Tubes 
are  also  made  in  such  a  manner  that  either  the  outer  or  inner  tube 
can  be  removed  and  replaced  without  disturbing  the  other.  Thus 
the  tube  lefl  in  place  acts  as  a  guide  for  the  insertion  of  the 
other. 

Intubation. — This  little  operation  consists  in  the  introduc- 
tion into  the  larynx  of  a  rigid  tube  so  as  to  permit  respiration  to 
go  on  in  spite  of  swelling,  or  an  accumulation  of  mucus  or  mem- 
brane, which  might  close  the  glottis.  It  is  chiefly  performed  in 
cases  of  diphtheria.  With  the  ingenious  instrument  devised  by 
O'Dwyer,  the  introduction  of  the  tube  is  comparatively  simple. 
The  patient  is  held  firmly  in  an  upright  position,  the  mouth  gag 
is  inserted,  and  the  forefinger  of  one  hand  is  passed  into  tbe  throat 
until  the  tip  of  the  epiglottis  can  be  felt.  With  this  finger  as  a 
guide,  the  tube  is  passed  into  the  larynx.  The  instrument  with 
which  the  tube  was  introduced  is  then  released  and  withdrawn, 
the  finger  holding  the  tube  in  position  meanwhile.  As  a  precau- 
tion against  mishaps,  the  tube  may  be  threaded  on  a  long  loop, 
and  the  thread  removed  only  when  the  operator  is  sure  the  tube  is 
in  position. 

In  removing  the  tube,  the  patient  is  again  placed  in  an  upright 
position,  the  mouth  gag  is  inserted,  and  the  forefinger  passed  into 
the  throat  until  tbe  tube  can  be  felt.  It  acts  as  a  guide  to  the 
extracting  instrument.  The  withdrawal  of  the  tube  is  more  diffi- 
cult than  its  insertion,  so  that  if  a  tube  is  inserted  merely  as  a 
temporary  measure,  it  is  well  to  leave  the  loop  of  thread  in  posi- 
tion to  facilitate  extraction.  If  this  is  done  the  loop  may  be  fas- 
tened over  the  patient's  ear. 

Sprain  of  the  Cervical  Spine. — The  lower  portion  of  the 
spine  is  more  often  the  seat  of  sprain  than  is  the  upper  portion. 
This  may  be  due  to  the  greater  flexibility  of  the  cervical  spine. 
However,  sprain  of  the  neck  is  by  no  means  uncommon.  It  may 
follow  falls  or  blows  of  various  sorts. 

The  symptoms  are  pain  and  tenderness,  especially  when  certain 
movements  are  made,  against  which  the  patient  often  protects  him- 
self by  muscular  contraction.  External  signs,  such  as  edema  and 
ecehvmosis,  are  usuallv  wanting.     There  is  no  true  deformity,  al- 


FRACTURES  123 

though  the  patient  for  his  own  comfort  may  keep  the  head  out 
of  the  median  line.  Thus  an  injury  of  this  sort,  if  not  properly 
treated,  may  lead  to  wryneck.  Symptoms  of  shock  may  be  pres- 
ent, but  are  usually  wanting  in  cases  of  simple  sprain. 

Diagnosis. — The  essential  point  in  the  diagnosis  is  not  to  over- 
look a  more  serious  injury,  such  as  fracture,  or  injury  of  the  cord, 
received  at  the  time  of  accident,  or  due  to  pressure  of  the  hema- 
toma. Hence  the  patient  should  be  carefully  examined,  the  ex- 
tent of  the  various  normal  motions  of  the  neck  tested  and  recorded 
(for  the  method  see  p.  162),  possible  paralysis,  either  sensory  or 
motor,  investigated,  and  any  other  symptoms  noted.  This  is  the 
more  important  in  cases  of  spinal  injury,  out  of  which  damage 
suits  may  arise. 

The  possibility  that  a  dislocation  lias  occurred  and  has  been 
spontaneously  reduced  should  also  be  borne  in  mind.  The  chief 
significance  of  this  is  the  damage  to  the  cord  which  may  have 
occurred  through  undue  pressure.  Another  possibility  to  be 
thought  of  is  commencing  tuberculosis. 

Treatment. — Treatment  consists  in  rest  in  a  correct  position, 
with  hot  or  cold  applications  to'  relieve  pain.  Later,  massage  and 
passive  and  active  motions  should  be  instituted  in  order  to  regain 
the  full  range  of  motion.  If  the  patient  has  a  tendency  to  hold 
the  head  in  an  abnormal  attitude,  this  should  be  corrected,  even 
though  it  is  necessary  to  give  an  anesthetic  and  to  apply  a  plaster 
of  Paris  bandage  to  the  head,  neck,  and  chest.  This  should  not 
be  continued  very  long,  lest  stiffness  result.  It  is  therefore  better 
to  remove  it  in  a  week,  and  to  begin  treatment  by  manipulation. 

Fractures. — Fracture  of  the  Hyoid. — Attempts  at  strangula- 
tion may  cause  fracture  of  the  hyoid  bone.  The  usual  symptoms 
of  fracture,  pain  on  motion,  swelling,  and  ecchymosis,  are  present 
but  may  be  rather  slight.  In  case  of  the  hyoid  bone,  crepitus  will 
probably  be  obtainable.  To  these  ordinary  symptoms  there  may 
be  added  pain  on  swallowing,  or  cough,  or  swelling  of  the  larynx 
so  great  that  tracheotomy  becomes  necessary.  If  no  displacement 
is  present,  the  parts  will  unite  without  treatment.  If  there  is 
displacement,  it  is  better  to  make  an  incision  and  suture  the 
fractured  cartilage  or  bone  with  catgut,  so  as  to  avoid  deformity. 
]STo  apparatus  is  required  to  hold  the  fractured  ends  in  normal 
position  if  there  is  no  tendency  to  displacement,  but  a  few  strips 


124  INJU1UES   AM)   INFLAMMATIONS   OF  THE  NECK 

oi  adhesive  plaster  or  immobilization  of  the  head  will  give  the 
patienl  comfort. 

Fracture  of  the  Larynx. — In  fractures  of  the  larynx  the  thyroid 
cartilage  is  usually  involved;  the  fracture  may  or  may  not  be 
complete.  A-  the  mucous  membrane  of  the  larynx  is  often  rup- 
tured, l>l»xxl  Hows  into  the  trachea  and  excites  a  most  painful 
cough.  Swallowing  and  talking  are  also  painful.  The  thyroid 
is  flattened;  there  is  marked  edema,  and  frequently  emphysema. 
If  the  fracture  is  complete,  crepitus  is  easily  obtained. 

This  is  a  very  dangerous  injury,  statistics  showing  that  more 
i ban  one-third  of  the  patients  who  suffer  from  it  die.  As  death 
usually  comes  during  an  attack  of  dyspnea,  tracheotomy  should  be 
immediately  performed,  except  possibly  in  simple  cases  when  the 
patient  is  so  situated  that  tracheotomy  can  he  performed  at  a 
moment's  notice.  Subsequent  treatment  should  be  directed  toward 
keeping  the  fracture  aseptic,  controlling  hemorrhage,  and  prevent- 
ing stenosis.  To  accomplish  these  measures  it  is  often  necessary 
to  perform  laryngotomy. 

Fracture  of  the  Trachea. — This  injury  occurs  less  often  than 
fracture  of  the  larynx.  The  symptoms  in  general  are  similar. 
Dyspnea  and  emphysema  are  the  most  alarming  ones,  and  are  fre- 
quently the  cause  of  death ;  or  death  may  follow  at  a  later  period 
from  inhalation  pneumonia. 

The  treatment  is  similar  to  that  recommended  for  fracture  of 
the  larynx.  If  there  is  no  dyspnea  and  no  emphysema,  trache- 
otomy may  be  deferred,  but  the  patient  should  be  kept  under  strict 
observation  for  several  days. 

Fracture  of  the  Cervical  Spine. — Fracture  of  the  cervical  ver- 
tebrae may  be  due  to  direct  violence,  but  it  is  generally  the  result 
of  blows  or  falls  upon  the  head.  It  is  not  necessarily  fatal,  but  is 
often  accompanied  by  injury  of  the  cord  sufficient  to  terminate 
life  either  immediately  or  after  the  lapse  of  a  few  weeks.  The 
symptoms  are  the  usual  ones  of  fracture,  namely,  pain  on  pres- 
sure and  on  manipulation,  abnormal  mobility  and  crepitus,  pos- 
sibly swelling  and  ecchymosis.  Some  of  these  symptoms  may  be 
masked  by  the  numerous  strong  muscles  which  surround  the  ver- 
tebra?, and  which  are  kept  contracted  to  prevent  the  pain  due  to 
motion  of  the  neck. 

The  cord  is  usually  injured,  either  pressed  upon,  or  partly  or 


CELLULITIS   AND   ERYSIPELAS  125 

wholly  crushed.  There  is,  therefore,  almost  always  more  or  less 
paralysis,  sensory  or  motor,  or  both. 

Prognosis,  on  account  of  the  injury  to  the  cord,  is  bad,  worse 
than  when  the  lumbar  spine  is  fractured. 

Treatment. — If  no  cord  symptoms  are  present,  treatment  con- 
sists in  the  immobilization  of  the  spine,  possibly  with  extension 
and  counterextension.  If  there  is  a  partial  or  complete  paralysis, 
the  spinal  canal  should  be  opened  posteriorly  (laminectomy),  and 
depressed  fragments  of  bone  or  compressing  blood-clots  removed. 
Unfortunately  the  paralysis  is  usually  due  to  crushing  of  the  cord 
at  the  time  of  the  accident,  and  not  to  pressure.  Hence  it  is  only 
occasionally  that  an  operation  benefits  the  patient. 

Dislocation  of  Vertebrae. — This  injury  may  be  due  either 
to  direct  violence  or  to  a  fall.  If  the  dislocation  is  complete,  it  is 
often  found  to  be  associated  with  fracture  and  to  have  produced 
fatal  lesions  of  the  cord.  There  are  instances,  however,  in  which 
dislocation  is  only  partial  and  in  which  the  cord  escapes  serious  in- 
jury. This  is  especially  true  when  a  partial  dislocation  takes 
place  between  the  axis  and  atlas.  Such  a  patient  may  escape 
paralytic  symptoms  and  may  live  with  the  dislocation  unreduced. 

Treatment. — If  the  head  and  body  are  pulled  strongly  apart 
and  the  neck  is  manipulated,  the  dislocation  may  be  reduced. 
This  procedure  is  not  without  risk  of  sudden  death.  It  should 
be  performed  with  the  greatest  steadiness  and  gentleness,  prefer- 
ably under  an  anesthetic.  Otherwise  the  treatment  consists  in 
immobilization  of  the  neck,  followed  by  massage  and  manipula- 
tions (compare  the  treatment  for  Sprain,  page  123). 

INFLAMMATIONS 

Burns. — The  neck  is  often  the  seat  of  severe  burns,  especially 
when  the  clothing  catches  fire.  Such  burns,  if  deep,  are  likely 
to  result  in  deforming  contractures,  even  to  the  extent  of  draw- 
ing the  chin  down  upon  the  chest  (Fig.  87,  p.  148).  For  the 
treatment  of  burns  see  page  26.  Contraction  should  be  prevented 
by  keeping  the  burned  area  extended  during  healing  by  means  of 
a  plaster  of  Paris  splint  fitted  to  the  opposite  side  of  the  neck. 

Cellulitis  and  Erysipelas. — Superficial  cellulitis  and  ery- 
sipelas occurring  in  the  neck  present  no  peculiar  features.     For 


L26  INJURIES    AND    INFLAMMATIONS   <>1<'   THE   NECK 

description  and  treatment  of  these  disorders  see  pages  33 
and  35. 

Boil. — The  back  of  the  neck  is  a  favorite  seat  for  boils.  A 
furuncle  or  boil  is  a  local  suppuration  due  to  staphylococci.  The 
inflammation  begins  in  the  skin  usually  at  the  root  of  a  hair. 
There  is  a  purulent  center,  surrounded  by  a  red,  edematous  area. 
The  swelling  and  pain  vary.  Sometimes  the  inflammation  is  so 
intense  that  necrosis  of  the  deeper  portion  of  the  skin  takes  place. 
This  necrotic  slough  is  called  the  "core"  of  the  boil.  If  the 
boil  forms  where  the  skin  is  delicate,  the  pus  very  soon  breaks 
through  to  the  surface.  In  the  back  of  the  neck,  where  the  skin 
is  often  a  quarter  of  an  inch  thick,  it  is  sometimes  several  days 
before  the  necrotic  center  of  the  boil,  popularly  called  the  core, 
becomes  softened  and  separated  from  the  surrounding  skin,  so  that 
the  contents  of  the  boil  are  able  to  discharge  themselves  spon- 
taneously ;  and  sometimes,  instead  of  discharging  on  the  surface, 
the  pus  finds  its  way  into  the  subcutaneous  fatty  tissue,  forming 
an  abscess  there.  A  boil  does  not  tend  to  spread  beyond  its 
immediate  vicinity,  and  after  its  discharge  it  usually  goes  on  to 
recovery  without  giving  rise  to  other  than  a  local  cellulitis.  The 
process,  however,  is  apt  to  be  repeated,  often  many  times,  in  the 
vicinity  of  the  first  lesion,  each  new  boil  developing  separately  as 
if  it  were  the  only  one,  from  infection  through  the  hair-follicles, 
due  to  the  smearing  of  pus  on  the  surface. 

Treatment. — The  best  treatment  is  to  evacuate  the  abnormal 
products  already  formed  and  to  hasten  or  cut  short  the  patho- 
logical process.  At  the  back  of  the  neck  the  skin  is  thick  and  the 
inflamed  area  is  proportionately  great,  so  that  the  introduction 
of  a  drop  of  carbolic  acid  will  not  usually  stop  the  infection,  as  it 
often  will  in  case  of  a  small  boil  of  the  face  (p.  36).  Most  sur- 
geons still  follow  the  domestic  plan  of  poulticing  such  a  lesion  for 
a  couple  of  days  until  there  is  a  well  marked  center  to  the  suppura- 
tion. This  poultice  treatment  is  generally  continued  too  long.  To 
keep  up  the  poultices  until  there  is  simply  a  soft  pus-sac  to  be 
opened  simplifies  the  operation,  but  it  prolongs  unnecessarily  the 
sufferings  of  the  patient,  and  by  increasing  the  size  of  the  cavity, 
which  lias  to  be  closed  in  healing,  it  delays  ultimate  recovery.  Tn 
most  instances,  as  early  as  the  second  day,  it  is  possible  to  say 
where  the  center  of  the  boil  is  located,  and  if  a  short  incision 


CARBUNCLE  127 

is  made  clear  through  the  skin  at  this  point  and  a  wet  dressing 
is  applied,  not  only  will  the  patient  be  saved  one  or  more  days 
of  intense  suffering,  but  the  inflammatory  process  will  rapidly 
subside  and  there  will  be  very  little  necrosis  of  the  skin  to  be 
made  good  by  the  growth  of  the  new  tissue.  Any  violent  attempts 
at  curetting  or  squeezing  out  the  necrotic  tissue  or  pathological 
products  are  to  be  condemned,  as  these  substances  will  come  out 
of  themselves  in  a  few  hours,  while  the  violence  adds  somewhat 
to  the  sum  total  of  injured  tissue  and  may  set  up  a  severe  cellu- 
litis. A  strip  of  rubber  tissue  or  gauze  should  be  inserted  to  favor 
the  escape  of  pus. 

An  injection  of  cocain  or  eucain  directly  into  the  inflamed 
skin  over  a  boil  is  a  very  painful  proceeding.  It  is  therefore  bet- 
ter to  begin  the  anesthetization  at  a  little  distance  from  the  in- 
flamed area,  so  that  as  new  punctures  are  made  nearer  the  center 
they  shall  enter  tissue  in  which  sensation  has  been  benumbed.  It 
is  in  operations  of  this  character  that  a  freezing  spray  of  ethyl 
chlorid  proves  satisfactory.  For  other  details  of  treatment  see 
Chapter  XX. 

The  after-treatment  of  a  boil  is  simple.  The  wet  dressings 
should  be  continued  for  a  couple  of  days,  until  the  discharge  is  at 
a  minimum,  when  an  ointment,  such  as  balsam  of  Peru,  one 
part,  vaseline,  eight  parts,  may  be  substituted. 

The  advantages  of  the  poultice  may  be  obtained  without  its 
disadvantages  by  applying  heat  to  the  outside  of  the  wet  dress- 
ing. For  this  purpose  a  hot-water  bag  or  bottle,  or  a  hot  brick 
or  flat-iron,  may  be  used.  It  is  easy  to  produce  and  maintain  as 
high  a  temperature  as  the  patient  can  stand,  by  changing  the 
bottle  as  soon  as  its  temperature  falls.  In  this  manner  the  gradual 
cooling  of  the  poultice  and  discomfort  and  trouble  of  its  renewal 
are  avoided. 

Carbuncle. — A  carbuncle  is  a  suppuration  which,  unlike  that 
of  a  boil,  has  a  tendency  to  spread  laterally  through  the  cutane- 
ous tissues.  Local  abscesses  are  formed  in  the  various  hair-folli- 
cles, and  the  interstices  of  the  skin  become  saturated  with  pus,  and 
there  is  an  extensive  cellulitis  with  necrosis  of  more  or  less  of 
the  true  skin,  besides  the  usual  symptoms  of  infection  (Fig.  74). 
A  carbuncle  also  extends  downward,  and  the  subcutaneous  fat  is 
usually  involved  in  all  except  very  mild  cases.     From  this  brief 


12S 


INJURIES    AND    INFLAMMATIONS   OF   Till:    M'.i'K 


description  it   appears  that  an  extensive  carbuncle   is  a  serious 
trouble  which  not  infrequently  terminates  fatally. 

[Treatment. —  It  is  important  that  incisions  should  he  made 
through  the  skin  before  the  process  lias  extended  widely.  As 
many  as  possible  of  the  small  abscesses  should  ho  opened  by  the 
incisions,  which  may  be  made  at  intervals  of  one-fourth  or  one- 


Fig.  74. — Carbuncle  of  Neck.     Note  the  flat  top,  and  several  points  of 

suppuration. 

third  of  an  inch,  both  vertically  and  horizontally;  or  they  may 
radiate  from  a  central  point  (Fig.  75).  Some  few  surgeons  ad- 
vocate the  complete  excision  of  a  carbuncle,  but  this  causes  the 
loss  of  an  unnecessary  amount  of  tissue.  A  compress  wet  with 
a  strong  antiseptic  solution  should  be  applied  and  kept  hot  in 
the  manner  described  above.  It  may  be  necessary  on  the  follow- 
ing day  or  at  a  later  period  to  make  other  incisions  to  permit  the 
escape  of  newly  formed  collections  of  pus.  Figure  76  shows  the 
outcome  of  a  very  bad  case. 


Fig.  75. — Carbuncle  of  Neck.  Duration,  four  weeks;  incised  three  times,  gangrene 
of  one  flap.  Scar  from  similar  operation  for  carbuncle  twenty  years  previous. 
Patient  aged  fifty-two  years. 


Fig.  7G — Same  Patient  as  Shown  in  Fig.  75,  but  Eleven  Weeks  Later. 

129 


130 


INJURIES   AND   INFLAMMATION'S   OF  THE  NECK 


Abscess.  AJbscesses  may  also  form  in  the  neck  as  the  result 
of  infection  in  some  other  situation.  This  is  notably  the  case  in 
neglected  children,  who  scratch  their  heads  to  find  relief  from  the 
itching  set  up  by  pediculi.  The  epidermis  is  broken,  a  slight 
cellulitis  results  in  the  scalp,  and  i lie  infection  follows  the  lym- 
phatics to  a  cervical  gland  and  produces  an  abscess  in  the  neck 
(  Fig.  77).  It  is  usually  possible  to  find  the  starting-point  of 
the  infection  under  such  circumstances.  Such  an  abscess  is 
wholly  subcutaneous  and  is  not  possessed  of  the  virulence  either 
of  the  boil  or  the  carbuncle.  It  should  be  opened  and  treated 
according  to  the  plan  laid  down  for  abscesses  of  the  scalp  (p.  31). 


I 

Fig.  77. — Abscesses  of  Neck.     Duration  two  weeks,  secondary  to  pediculosis  capitis, 
occurring  in  a  child  of  two  years. 

The  pediculi  should  be  removed  to  prevent  recurrence  of  the 
trouble.  Applications  of  benzin,  or  kerosene,  or  tincture  of 
delphinium  and  ether,  followed  by  a  shampoo,  will  accomplish  this. 

Deep  suppuration  of  the  neck,  due  presumably  to  infection 
from  the  mouth,  sometimes  develops  rapidly.     In  a  day  or  two 


ABSCESS 


131 


the  whole  front  or  side  of  the  neck  may  be  swollen,  brawny, 
and,  later,  saturated  with  pus,  while  chills  and  fever  show  the 
gravity  of  the  affection.  This  trouble  has  often  been  called 
angina  Ludovici.     It  deserves  early  radical  treatment  or  it  may 


Fig.  78. 


-Abscess.  Under    Stermqmastoid  Muscle.     Six  months'  duration; 
probably  tubercular.     Patient  aged  fifty-six  years. 


speedily  lead  to  a  fatal  termination.  The  tension  should  be  re- 
lieved by  incisions  sufficiently  numerous  and  deep  to  open  any 
pockets  of  pus  and  allow  the  escape  of  the  greater  part  of  the 
exuded  fluid.  If  operation  is  delayed  until  the  whole  front  of  the 
neck  is  involved,  the  prognosis  is  decidedly  unfavorable. 

A  slowly  forming  deep  abscess'  of  the  neck  may  be  due  to 
breaking  down  of  a  tuberculous  gland  (Tig.  78),  or  to  a  mixed 
infection  in  case  of  syphilitic  ulcerated  throat.  Abscess  of  the 
cervical  lymphatic  glands  secondary  to  alveolar  abscess,  is  spoken 
of  on  page  42. 
11 


132  INJURIES   AND   INFLAMMATIONS  OF  THE  NECK 

Anthrax.- — Anthrax  or  malignant  pustule  is  a  disease  not 
common  in  this  country.  It  usually  develops  in  a  man  who  has 
been  handling  infected  hides.  The  first  lesion  appears  upon  the 
hand  or  some  part  of  the  body  that  the  hand  has  touched.  It 
is  a  hard,  raised,  flattened,  reddish  nodule,  with  a  surrounding 
zone  of  more  or  less  indurated  cellulitis  (Fig.  79).     It  shows  little 


Fig.  79. — The  Primary  Lesion  of  Anthrax.     Diagnosis  confirmed  by  microscopical 
examination  of  discharge  from  the  ulcer,  and  of  the  blood. 

tendency  to  necrose  in  the  central  portion.  The  constitutional 
symptoms  are  severe  and  out  of  proportion  to  the  local  mani- 
festations, although  they  may  not  become  so  until  several  days 
after  the  infection  has  taken  place.  The  diagnosis  can  only  be 
made  with  certainty  by  an  examination  of  the  serum  and  blood 
obtained  from  the  pustule.  The  anthrax  bacillus  is  large  and 
has  square  ends,  like  the  segments  of  a  mature  tapeworm,  so  that 
it  is  readily  recognized  in  a  stained  smear  by  a  simple  micro- 
scopical examination.     As  confirmatory  evidence,  cultures  should 


CERVICAL  TUBERCULOSIS  133 

be  made.  The  bacillus  grows  readily  upon  any  of  the  common 
culture  media.  If  a  positive  diagnosis  is  made,  the  local  lesion 
should  be  immediately  excised.  Further  operative  measures  are 
generally  useless,  as  the  disease  spreads  through  the  blood  as  well 
as  through  the  lymphatic  system.  A  fatal  termination  is  common, 
but  is  by  no  means  invariable,  so  that  life  should  not  be  despaired 
of  at  once. 

Cervical  Tuberculosis. — Tuberculosis  in  the  neck  is  situ- 
ated either  in  the  lymph-glands  or  in  the  spine.  Tubercular 
lymphadenitis  is  described,  with  other  enlargements  of  the  glands, 
on  page  142. 

Tuberculosis  of  the  bones  of  the  neck  or  cervical  Pott's  dis- 
ease, as  it  is  called,  is  a  condition  which  in  its  early  stages  is  apt 
not  to  be  recognized.  Owing  to  the  fact  that  the  spines  of  the 
vertebrae  are  not  so  plainly  to  be  felt  as  those  in  the  back  and  in 
the  lumbar  region,  the  diagnosis  is  not  so  simple  as  it  is  in  the 
latter  situations.  The  first  symptoms  noticed  are  pain,  stiffness, 
and  rigidity  of  the  neck.  Later  there  is  swelling  of  a  diffuse 
character,  making  the  neck  somewhat  thicker  than  before.  There 
is  great  pain  when  the  neck  is  bent,  either  by  the  patient  or  by 
the  examiner.  The  trouble  may  be  differentiated  from  acute  sup- 
puration by  the  gradual  onset  of  the  disease,  by  the  low  fever,  and 
the  absence  of  surface  heat,  edema,  and  redness.  From  wryneck 
and  the  acute  myositis  which  precedes  wryneck,  it  can  be  differen- 
tiated by  the  situation  of  the  swelling.  In  cervical  Pott's  the 
swelling  is  invariably  in  the  median  line,  though  it  may  extend 
more  to  one  side  or  the  other.  In  myositis  or  wryneck  the  swelling 
is  lateral  or  well  to  the  front.  In  wryneck  the  chin  is  directed 
away  from  the  side  on  which  the  sternomastoid  muscle  is  prom- 
inent. In  cervical  Pott's  the  chin  is  directed  toward  the  affected 
side.  In  wryneck  correction  of  the  deformity  is  prevented  by  the 
bands  which  spring  into  marked  relief  when  correction  is  at- 
tempted. In  cervical  Pott's  an  attempt  to  correct  the  deformity 
is  painful,  and  will  be  resisted  by  the  hands  of  the  patient. 

Cervical  Pott's  is  differentiated  from  deforming  arthritis  of 
the  spine  by  the  fever  which  it  causes,  by  the  involvement  of  the 
soft  parts  in  the  tuberculous  inflammation,  by  the  greater  tender- 
ness, and  by  the  age  of  the  patient,  much  less  in  tuberculosis  than 
in  arthritis  in  most  cases.     The  progressive  rigidity  of  the  spine 


134  INJURIES  AND   INFLAMMATIONS  OF  THE   NECK 

which  occurs  in  arthritis  is  absolutely  characteristic  as  the  disease 
becomes  more  advanced. 

Treatment. — The  object  of  treatment  is  to  obtain  relief  from 
the  weight  of  the  head  and  to  keep  the  parts  at  rest.  This  is 
accomplished  by  an  apparatus  known  as  a  jury-mast  which  lifts 
the  weight  of  the  head  by  a  strap  placed  under  I  lie  occiput  and 
under  the  chin.  The  instrument  rests  upon  the  back  and  shoul- 
ders and  is  secured  in  place  either  by  straps  or  by  a  plaster  of 
Paris  bandage.  Whether  the  disease  will  he  arrested  or  progress 
to  an  unfavorable  termination  will  depend  upon  the  age  of  the 
patient,  the  hygienic  surroundings,  etc.,  more  than  upon  local 
treatment. 

Deforming  Arthritis. — The  spine  is  involved  in  deforming 
arthritis  with  a  frequency  not  generally  recognized.  At  times 
the  whole  spine  is  involved,  hut  oftener  only  a  portion  of  it.  The 
neck  is  the  part  most  often  affected.  One  writer  has  stated  that, 
in  more  than  one  third  of  all  cases  of  deforming  arthritis  the  cer- 
vical vertebra?  are  involved.  On  account  of  the  irregular  shape 
and  close  articulations  of  the  vertebra1,  the  disease  is  apt  to  pro- 
duce a  firm  ankylosis  of  the  portion  of  the  spine  involved.  The 
most  marked  symptoms  are  increasing  stiffness,  and  pain  due  to 
pressure  upon  the  posterior  roots  of  the  spinal  nerves.  Zoster  also 
occurs.  The  differentiation  of  this  disease  from  cervical  tubercu- 
losis has  been  given  on  the  preceding  page. 

The  treatment  should  be  both  local  and  general.  Massage,  hot 
baths,  and  counterirritants  may  be  used  to  relieve  the  pain.  The 
general  treatment  will  vary  according  to  the  ideas  of  the  physician 
in  regard  to  deforming  arthritis.  My  own  preference  is  for  a  resi- 
dence away  from  large  bodies  of  water,  for  an  out-of-door  life,  free 
from  care,  and  with  all  the  good  food  that  the  patient  can  take 
without  producing  symptoms  of  indigestion. 


CHAPTER    V 
TUMORS    AND    DEFORMITIES    OF    THE    NECK 

TUMORS 

Sebaceous  Cyst. — This  variety  of  tumor  is  found  in  the 
skin  of  the  front  and  back  of  the  neck,  but  with  less  frequency 
than  upon  the  head.  It  presents  no  peculiarities  on  account  of  its 
situation,  so  that  what  has  been  said  of  the  diagnosis  and  treat- 
ment of  sebaceous  cysts  of  the  head  is  applicable  here  (see  p.  66). 

Thyroid  Cyst.     (See  Goiter,  p.  145.) 

Thyreoglossai  Cyst. — The  region  of  the  larynx  is  a  favor- 
able site  for  congenital  cysts  and  sinuses  developing  from  some 
remains  of  the  thyreoglossai  duct,  which  at  an  embryological  pe- 
riod extends  from  the  base  of  the  tongue  through  the  hyoid  to  the 
thyroid  cartilage.  If  the  remains  of  such  a  duct  open  externally, 
one  or  more  sinuses  will  persist  and  will  discharge  mucus.  If  the 
remains  of  the  duct  do  not  open  externally  or  into  the  mouth,  the 
secretion  may  give  rise  to  a  cyst  containing  mucus.  Such  a  cyst  is 
easily  opened  and  its  contents  evacuated,  and  the  sutured  skin  will 
heal  per  primam.  In  the  course  of  a  few  days  or  weeks,  however, 
the  fluid  will  reaccumulate  and  the  tumor  will  reappear.  In  order 
to  avoid  this  unpleasant  result  the  treatment  should  be  thorough. 
The  scar  following  an  unsuccessful  attempt  to  remove  a  thyreo- 
glossai cyst  is  shown  in  Fig.  80.  This  also  shows  the  situation  of 
the  original  sinus  or  cyst.  If  a  sinus  exists,  it  is  invariably  in  the 
median  line. 

Treatment. — The  only  successful  treatment  is  the  complete 

removal  of  the  cyst  and  its  duct.     The  situation  is  a  conspicuous 

one  and  it  is  desirable  to  leave  as  small  a  scar  as  possible,  yet  the 

dissection  must  be  deep  enough  to  expose  the  abnormal  tissue,  both 

above  and  below  the  hyoid  bone  if  need  be.     The  skin  should  be 

cocainized  or  the  patient  given  a  general  anesthetic.     The  incision 

135 


136 


TUMORS    AM)    DEFORMITIES   OV  THE   NECK 


should  be  mad*-'  directly  in  the  median  line  and  more  above  than 
below  the  center  of  the  tumor,  as  it  is  necessary  to  follow  it  up- 
ward. The  dissection  and  removal  of  a  rounded  cyst  is  easy;  that 
of  a  narrow  sinus  is  more  difficult,  since  it  is  often  impossible  to 
recognize  it  when  it  becomes  attenuated.     Even  when  there  is  a 


Fig.  80. — Thyreoglossal  Cyst;  Operation;  Recurrence.     Note  the  position  of 
the  cyst  in  the  median  line  just  below  the  hyoid  bone. 


well  marked  cyst,  an  inconspicuous  sinus  often  leads  from  its 
upper  part.  It  has  been  suggested  that  such  a  sinus  be  injected 
with  a  solution  of  methyl  blue,  so  that  the  operator  may  follow 
it  more  readily. 

"When  the  congenital  tissue  has  been  followed  to  the  hyoid 
1  one  there  will  often  be  found  a  perforation  of  the  bone.  The 
lining  of  this  should  be  curetted  away,  and  if  the  sinus  exists 
above  the  hyoid  it  should  be  followed  and  removed.  When  this 
l.as  been  done,  the  patient  will  have  been  given  the  best  chance 
against  recurrence,  but  a  guarded  prognosis  should  be  given.  The 
wound  should  be  sutured  entirely,  or  over  a  minute  drain  in  its 
lower  angle. 


LIPOMA  137 

Branchiogenic  Cysts  and  Sinuses. — Other  congenital  cysts 
and  sinuses  may  be  found  in  the  sides  of  the  neck,  having  de- 
veloped from  the  remains  of  the  branchiogenic  clefts,  or  at  the 
base  of  the  ear  and  posterior  to  it.  These  tumors  are  some- 
times made  up  of  a  few  larger  cysts  and  innumerable  smaller 
ones,  and  contain  either  a  clear  serous  fluid  or  one  made  thicker 
by  the  presence  of  mucin  and  other  albuminous  substances.  They 
are  .benign  in  character,  but  on  account  of  the  deformity  and  their 
tendency  to  keejj  on  growing  they  should  be  removed  as  thoroughly 
as  possible. 

In  making  a  diagnosis  of  a  lateral  cervical  cystic  tumor, 
aneurism  of  the  carotid  or  one  of  its  branches  should  always  be 
considered.  One  thinks  at  once  of  expansile  pulsation  as  a  means 
of  differential  diagnosis.  It  should  be  borne  in  mind  that  if  a 
tumor,  cystic  or  solid,  lies  upon  the  carotid  artery  it  receives  an 
impulse  from  the  arterial  beat.  This  impulse  may  be  mistaken 
for  expansile  pulsation  unless  a  careful  examination  is  made. 

Lipoma. — A  fatty  tumor  or  lipoma  is  probably  the  com- 
monest solid  tumor  of  the  neck.  It  occurs  in  three  forms :  simple, 
diffuse,  and  intermuscular. 

A  simple  lipoma  is  a  well  encapsulated  tumor  lying  in  the 
subcutaneous  plane  of  fascia.  It  seems  to  form  a  part  of  the  sub- 
cutaneous fat,  but  it  soon  exceeds  this  fat  in  thickness  and  is  usu- 
ally covered  by  a  thin  layer  of  this  fat.  It  may  be  found  in  any 
portion  of  the  neck  (Fig.  81).  It  tends  to  grow  larger,  and  this 
causes  an  ever-increasing  deformity.  This  is  the  one  reason  for 
its  removal. 

Treatment. — A  local  anesthetic  is  sufficient  unless  the  pa- 
tient is  very  sensitive.  The  incision  in  the  skin  should  usually 
be  parallel  to  or  lie  in  one  of  the  circular  wrinkles  of  the  neck. 
A  transverse  incision  is  also  preferable  if  the  tumor  is  situated 
at  the  back  of  the  neck  The  incision  should  be  deepened  until 
the  capsule  of  the  tumor  is  plainly  seen.  This  is  usually  covered 
by  some  normal  subcutaneous  fat,  and  if  the  operator  attempts  to 
dissect  out  the  tumor  before  the  true  capsule  is  reached,  the  diffi- 
culties are  unnecessarily  increased  and  a  ragged  cavity  will  result. 
When  the  correct  plane  is  reached  the  whole  tumor  can  be  quickly 
shelled  out  with  blunt  dissection  either  with  the  fingers  or  with 
closed,  blunt-pointed,  curved  scissors.     There  is  scarcely  any  bleed- 


• 

■                     /I 

«■ 

\o*                                                               1 .' 

Fig.  81. — Simple  Lipoma  of  the  Neck  of  Two  Years'  Duration. 


Fig.  82. — Diffuse  Lipoma  of  the  Neck.     This  tumor  was  symmetrically  bilateral. 
One  portion  was  removed  five  days  before  the  photograph  was  taken. 
138 


LIPOMA 


139 


ing,  but  the  wound  should  he  inspected  for  it,  and  if  any  Needing 
vessel  exists,  it  should  he  ligated  with  fine  catgut  lest  a  hematoma 
fill  the  cavity  left  by  the  removal  of  the  lipoma,  and  for  a  time 
continue  the  deformity.  The  wound  should  be  completely  sutured 
with  horsehair  or  fine  black  silk  and  elastic  pressure  applied  by 
means  of  a  gauze  and  cotton  dressing  and  a  firm  bandage.  This 
may  be  removed  in  three  days  and  any  small  dry  dressing  be 


Fig.   83. — Fibroma   of  Nine    Years'   Duration,   Apparently    Starting  in   the 
Fascia  about  the  Sternomastoid  Muscle. 


reapplied.  The  stitches  should  be  removed — one-half  on  the 
fourth  day  and  one-half  on  the  sixth  day,  or  sooner  if  the  wound 
is  a  small  one. 

Diffuse  Lipoma. — The  second  variety  of  lipoma  develops  in  con- 
nection with  the  deep  fascia.  It  is  not  encapsulated;  it  contains 
more  fibrous  tissue  than  the  other  two  varieties,  and  its  removal 


140 


TUMORS    AND    DEFORMITIES   OF   THE   NECK 


is  difficull  and  unsatisfactory.     It  usually  develops  symmetrically 
on  both  sides  of  the  neck  (Fig.  82).     Fortunately  it  is  rare. 

Intermuscular  Lipoma. — The  third  variety  of  lipoma  develops 
in  the  fascia  between  the  muscles.  It  is  found  in  the  neck,  trunk, 
and  extremities.  In  structure  it  resembles  the  simple  lipoma, 
being  made  up  of  lobules  of  almost  pure  fat,  each  surrounded  by 
a  complete  delicate  capsule.  The  dissection  for  its  removal  is 
therefore  easy,  but  the  extensive  ramification  of  the  tumor  between 
the  various  muscles  sometimes  makes  necessary  a  pretty  long 
wound. 

Fibroma. — A  pure  fibroma,  wholly  subcutaneous,  is  not  a 
very  common  tumor  in  any  portion  of  the  body.  Such  a  one  de- 
veloping slowly  in 
connection  with  the 
left  sternomastoid 
muscle  is  shown  in 
Figure  83.  It  was 
removed  without,  dif- 
ficulty, being  fully  en- 
capsulated (Fig.  81). 
Enlarged  Lym- 
phatic Glands.  — 
Acute  Lymphadenitis. 
— The  most  common 
tumor  of  the  neck  is 
a  swollen  lymph- 
gland.  In  the  strict 
use  of  the  term  this 
is  not  a  tumor  at  all 
but  an  inflammation, 
a  lymphadenitis.  But 
for  clinical  reasons  it 
is  well  to  class  these 
enlarged  glands  with 
the  tumors.  The  cer- 
vical glands  are  especially  liable  to  swell  on  account  of  infection 
from  bad  teeth,  or  from  throat  troubles,  such  as  ulcerated  tonsil, 
or  from  inflammation  in  or  about  the  ear,  as  Avell  as  from  infected 
wounds  of  the  skin.     A  very  common  source  of  lymphadenitis  of 


Fig.  84. — Same  Subject  as  Fig.  83,  Showing  the 
Tumor  after  Removal.  It  was  fully  encapsu- 
lated and  easily  removed. 


ENLARGED   LYMPHATIC   GLANDS  141 

the  posterior  cervical  glands  in  children  is  pediculosis  capitis.  The 
child  scratches  the  scalp  to  relieve  itself  of  the  intolerable  itching, 
the  scratches  become  infected,  and  the  glands  swell.  An  extreme 
case  in  which  the  glands  have  broken  down  and  two  largo  abscesses 
have  resulted  is  shown  in  Figure  77,  page  130. 

Whatever  the  source  of  infection,  the  glands  lying  in  the 
path  of  the  afferent  lymph- vessels  will  become  inflamed.  One  or 
more  of  them  swells  until  it  presents  itself  as  a  smooth,  round, 
movable  tumor,  above  which  the  skin  is  also  freely  movable.  If 
the  severity  of  the  inflammation  causes  the  gland  to  break  down, 
fluctuation  is  obtainable  and  the  inflammation  extending  to  the 
skin  will  prevent  movement  of  the  latter  over  the  gland.  Later 
the  abscess  may  break  through  the  skin.  Often,  however,  the 
infection,  being  of  a  milder  character,  does  not  extend  beyond 
the  capsule  of  the  gland,  and  the  acute  symptoms  of  infection  are 
wanting  in  the  periglandular  tissue ;  or  the  inflammation  in  the 
glands  themselves  may  be  of  a  more  chronic  form.  In  such  a 
case  the  swelling  of  the  gland  will  be  painless,  and  there  will  be 
little  tenderness  even  on  pressure. 

One  should  never  be  satisfied  with  a  diagnosis  of  simple 
lymphadenitis.  The  source  of  the  infection  should  also  be  de- 
termined. If  no  cause  for  the  swelling  of  the  gland  can  be 
ascertained,  the  possibility  of  tuberculosis  should  be  kept  in 
mind. 

Treatment. — If  the  infection  of  the  gland  has  not  proceeded 
to  demonstrable  suppuration,  the  attention  may  be  directed  to  the 
prevention  of  further  infection  by  the  treatment  of  the  infected 
teeth,  or  sore  throat,  or  wound  of  the  skin.  When  the  source  of 
infection  has  been  shut  off,  acute  lymphadenitis  will  take  care  of 
itself  in  many  cases. 

If  fluctuation  can  be  made  out  in  a  gland,  the  process  will 
rarely  undergo  resorption  without  a  discharge  of  pus.  In  such 
cases  it  is  better  therefore  either  to  drain  the  gland  or  to  remove 
it  entirely  if  this  can  be  readily  done.  For  if  the  glandular  tissue 
is  riddled  with  pus  and  germs,  but  has  not  necrosed,  the  relief  of 
tension,  when  the  abscess  is  incised,  will  give  it  a  new  lease  of  life, 
so  that  this  glandular  tissue  may  remain  a  long  time  in  the  wound, 
discharging  constantly  a  purulent  secretion  and  delaying  wouud- 
healing  in  an  aggravating  manner.     If  the  whole  gland  is  removed 


142  TUMORS   AND  DEFORMITIES   OF  THE   NECK 

with  its  capsule,  union  of  the  sides  of  the  wound  will  be  prompt 
and  often  primary. 

If  the  infection  comes  from  the  front  teeth,  so  that  the  tumor 
forms  in  the  situation  of  the  submaxillary  gland,  this  gland  is  ex- 
posed first  in  making  the  incision.  It  ought  not  to  be  sacrificed, 
however,  because  the  source  of  the  pns  is  not  in  its  substance,  but 
in  that  of  one  or  more  lymphatic  glands  lying  just  under  it.  If 
this  caution  is  not  borne  in  mind,  the  salivary  gland  may  be  need- 
lessly excised. 

Chronic  Lymphadenitis,  or  Tuberculous  Glands. — The  lymphatic, 
glands  of  the  neck  arc  also  subject  to  inflammatory  processes  of 
a  chronic  character.  Many  times  the  process  is  distinctly  tuber- 
cular, and  can  be  shown  to  be  such  by  the  presence  of  tubercle 
bacilli  in  the  excised  gland.  At  other  times,  however,  the  tumor 
develops  in  a  similar  manner  and  presents  the  same  clinical  appear- 
ances, although  no  tnberele  bacilli  can  be  made  out.  Such  patients 
are  anemic,  have  a  poor  digestion,  suffer  from  cold  feet  and  hands, 
and  have  an  appearance  of  malnutrition  although  the  subcutaneous 
fatty  tissue  may  be  abundant. 

Treatment. — The  treatment  in  tuberculosis  is  primarily  hy- 
gienic. Such  treatment  should  precede  and  follow  the  local  treat- 
ment. Just  what  the  local  treatment  should  be  must  be  determined 
in  each  particular  case.  If  a  single  large  gland  exists,  causing  a 
deformity  and  suggesting  the  possibility  of  enlargement  of  other 
glands,  its  removal  is  absolutely  indicated.  If  there  are  many 
slightly  enlarged  glands  operation  can  be  deferred.  If  there  are 
numerous  large  glands,  some  of  which  are  plainly  suppurating, 
removal  is  necessary  both  to  reduce  the  number  of  foci  from 
which  the  disease  may  spread  as  well  as  to  save  the  patient  from 
abscess  formation  with  resulting  sinuses  and  disfiguring  cicatrices. 

If  a  single  movable  gland  is  to  be  removed,  a  local  anesthetic 
suffices  in  many  cases.  If  many  glands  are  enlarged,  and  espe- 
cially if  one  or  more  are  adherent,  the  operation  is  a  more  formi- 
dable one  and  had  better  not  be  undertaken  except  with  general 
anesthesia;  for  although  the  enlarged  glands  may  seem  to  lie 
close  to  the  surface,  they  invariably  extend  deeper  than  they  ap- 
pear to  do,  and  almost  always  there  are  others  still  deeper  which 
are  concealed  by  the  more  superficial  ones.  A  thorough  opera- 
tion in  such  cases  means  a  free  incision  of  the  skin  and  superficial 


ENLARGED   LYMPHATIC   GLANDS  143 

muscles  and  wide  exposure  of  the  cervical  vessels.  Such  glands 
often  lie  just  in  front  of  the  sternomastoid  muscle  and  close  to 
the  internal  jugular  vein;  others  are  usually  found  just  behind 
the  muscle,  or  beneath  it.  Hence  the  division  of  this  muscle 
greatly  facilitates  their  removal.  A  transverse  or  U-shaped  or 
Z-shaped  incision  through  the  skin  is  advocated  on  account  of 
the  splendid  exposure  it  gives.  The  resulting  scar  is  prominent, 
and  should  he  avoided  when  possible,  even  though  two  separate 
incisions  are  required — one  in  front  of  the  sternomastoid  and  one 
behind  it.  In  cases  of  extensive  involvement  of  the  glands,  it  is 
well  to  remove  as  much  of  the  gland-bearing  fascia  as  possible-. 
This  requires  a  long  and  difficult  dissection,  which  is  fully  de- 
scribed in  good  text-books  on  major  surgery. 

The  cases  which  may  properly  be  considered  here  are  those 
in  which  there  are  one  or  more  enlarged  glands,  freely  movable 
and  easily  accessible.  In  such  a  case  it  is  better  to  make  the  in- 
cision directly  over  the  glands  and  parallel  to  the  edge  of  the 
sternomastoid  muscle.  When  the  various  planes  of  tissue,  skin, 
subcutaneous,  and  deep  fascia  have  been  divided,  there  will  be  ex- 
posed the  outer  capsule  of  the  gland.  If  this  is  also  divided,  the 
gland  may  sometimes  be  shelled  out  like  the  pulp  of  a  grape  from 
its  skin,  especially  if  it  is  still  solid  and  the  inflammation  has  not 
set  up  adhesions  between  the  gland  substance  and  the  outer  cap- 
sule. In  that  case  the  dissection  may  be  tedious,  but  should  be 
persisted  in  until  the  gland  is  removed.  The  rule  should  always 
be  to  keep  close  to  the  gland  in  removing  it.  If  a  little  of  the 
gland  substance  remains,  it  is  easy  to  remove  it  after  the  gland 
itself  has  been  excised ;  whereas  if  the  line  of  incision  strays  from 
the  gland  itself,  serious  damage  may  be  done  to  some  important 
vessel  or  nerve. 

The  important  structures  to  be  kept  in  mind  during  the  dis- 
section are  the  internal  jugular  vein  and  pneumogastric  nerve  in 
front  of  the  sternomastoid  muscle,  and  the  spinal  accessory  nerve 
posterior  to  it. 

When  the  enlarged  glands  have  been  removed  the  wound 
should  be  cleansed  and  sutured.  Even  though  necrotic  material 
has  been  smeared  over  the  wound  by  the  rupture  of  a  softened 
gland,  primary  union  is  still  attainable  in  most  cases  if  all  dis- 
eased glands  are  removed.     The  finest  of  black  silk  sutures  should 


1  11  TUMORS   AND   DEFORMITIES   OF  THE   NECK 

be  placed  through  the  skin  wound,  thus  allowing  the  deeper  parts 
to  collapse  and  assume  their  normal  relation.  Light  pressure  ob- 
tained by  a  piece  of  sterik'  gauze  placed  on  the  wound  and  cov- 
ered with  cotton  and  a  gauze  bandage  will  suffice  to  keep  the 
deeper  parts  of  the  wound  in  apposition.  If  the  wound  is  dry 
before  it  is  sutured  no  hemorrhage  need  be  feared.  Even  if  the 
dissection  is  a  limited  one,  it  is  better  to  confine  the  movements 
of  I  he  head  for  two  or  three  days  by  the  application  outside  of  the 
gauze  bnndage  of  a  starch  bandage,  made  by  tearing  heavy  crin- 
olin  into  strips  t\v< >  < >r  three  inches  wide.  These  strips  are  rolled  and 
immediately  before  being  used  they  are  wrung  out  of  hot  water, 
care  being  taken  not  to  squeeze  out  more  of  the  contained  starch 
than  is  necessary.  In  the  case  of  a  child,  or  of  a  restless  adult, 
the  bandage  should  run  around  the  neck,  up  the  back  of  the  head 
and  around  the  forehead,  and  should  also  extend  under  one  or 
both  arms  (No.  22,  Chapter  XXI).  This  may  seem  like  a  very 
extensive  dressing  for  a  simple  wound,  but  only  in  this  manner  can 
a  wound  in  the  neck  be  properly  protected  and  the  head  kept  quiet. 
In  a  day  or  two,  when  the  starch  has  thoroughly  dried,  the  parts 
of  the  bandage  which  extend  under  the  arms  may  be  cut  away, 
as  by  that  time  the  molding  of  the  bandage  to  the  shape  of  the 
neck  and  shoulders  will  be  sufficiently  firm.  The  wound  should 
be  dressed  in  four  days,  and  half  of  the  stitches  removed,  the  rest 
being  left  in  three  or  four  days  longer.  From  this  time  on  a 
cotton-collodion  dressing  will  sufficiently  protect  the  wound  from 
outside  contamination.  If  the  adult  is  quiet  and  the  incision  does 
not  extend  to  the  upper  third  of  the  neck,  the  bandage  around 
the  head  may  be  omitted. 

Suppurating  Tuberculous  Glands.  —  Unfortunately  the  clean 
operations  above  described  are  often  impossible  because  the  pa- 
tient will  not  allow  any  operation  until  the  pus  has  burst  through 
the  skin  or  at  least  has  ruptured  the  capsule  of  the  gland  and  has 
infiltrated  the  surrounding  tissues.  Under  such  circumstances  the 
abscess-cavity  must  be  drained  through  a  suitable  incision,  but  the 
operator  should  not  content  himself  with  this  alone,  but  should 
make  an  attempt  to  remove  all  of  the  affected  gland,  either  by 
means  of  a  curette  or,  what  is  better,  by  means  of  forceps  and 
scissors.  If  this  dissection  does  not  extend  beyond  the  original 
capsule  of  the  broken-down  gland,  the  risk  of  spreading  the  infec- 


TUMORS   OF  THE  THYROID   01  .AND  145 

tion  by  this  treatment  is  not.3K.Qith  considering,  and  the  period  of 
recovery  will  be  materially  shortened  if  one  does  not  Leave  behind 
a  half  disintegrated  gland,  which  will  keep  ;i  sinus  discharging  a 
small  amount  of  pus  daily  for  weeks  afterward.  If,  on  the  other 
hand,  the  gland  is  wholly  removed,  and  free  drainage  is  given 
to  the  wound,  it  may  be  able  to  close  by  granulation  in  a  week 
or  two. 

In  Syphilis. — The  cervical  glands  may  be  enlarged  in  syphilis 
either  as  an  accompaniment  of  an  ulcerated  throat  or  as  a  later 
manifestation  of  the  disease.  In  the  former  case,  on  account  of 
the  presence  of  pus,  an  incision  may  be  necessary.  Glandular 
enlargement  due  to  syphilis  will  subside  rapidly  under  antisyph- 
ilitic  treatment,  so  that  removal  of  the  glands  is  not  usually 
necessary. 

In  Leukemia,  Pseudoleukemia,  Sarcoma,  Carcinoma. — Other 
causes  of  chronic  lymphadenitis  are  leukemia,  Hodgkin's  disease, 
and  the  malignant  tumors.  It  is  well  worth  remembering  that 
the  cervical  glands  above  the  left  clavicle  have  connection  with  the 
abdominal  organs  through  the  lymphatics  which  accompany  the 
thoracic  duct;  and  they  may  enlarge  so  as  to  be  easily  palpable, 
before  the  patient  seeks  advice  for  a  gastric  or  hepatic  cancer. 

Tumors  of  the  Thyroid  Gland,  or  Goiter. — The  thy- 
roid gland  is  frequently  the  seat  of  hypertrophy  and  new  growth. 
There  may  be  a  diffuse  enlargement  of  a  part  or  the  whole  of  the 
gland,  or  there  may  be  well  marked  nodules,  either  cystic  (Fig. 
85)  or  parenchymatous  in  structure.  Any  such  benign  swelling 
of  the  thyroid  gland  is  known  as  a  goiter.  This  is  a  common 
affection  in  certain  mountainous  districts  in  Europe,  but  it  is  by 
no  means  confined  to  them,  and  seems  to  be  increasing  in  fre- 
quency in  New  York  City,  possibly  on  account  of  immigration 
from  such  regions.  The  larger  swellings,  involving  the  whole 
gland  if  of  parenchymatous  nature,  are  sometimes  associated  with 
protrusion  of  the  eyeballs  and  certain  nervous  symptoms.  Such 
a  goiter  is  called  exophthalmic  goiter  (Fig.  86). 

Diagnosis. — Tumor  of  the  thyroid  may  be  recognized  by  the 
fact  that  it  is  drawn  strongly  upward  when  the  patient  swallows, 
on  account  of  the  close  attachment  of  the  thyroid  gland  to  the 
larynx.  It  is  not  so  easy  to  tell  a  cystic  from  a  discrete  parenchy- 
matous swelling.     A  diffuse  swelling  of  even  elastic  consistence 


146 


CICATRICES  147 

throughout  is  invariably  parenchymatous.  A  large  cyst  will  yield 
a  fluctuation  wave  when  tapped  upon  or  compressed.  A  small 
cyst  and  a  small  parenchymatous  nodule  react  about  alike  in  this 
respect.    An  aspirating  needle  will  distinguish  the  two. 

Treatment. — The  removal  of  a  cystic  or  a  parenchymatous 
nodule  is  not  a  difficult  procedure  if  the  surgeon  is  careful  to  con- 
trol hemorrhage  step  by  step.  Local  anesthesia  is  sufficient.  The 
best  incision  is  jDarallel  to  the  transverse  wrinkles  of  the  neck. 
The  deep  fascia  is  divided,  any  intervening  muscle  freed  and 
pulled  to  one  side,  and  the  gland  exposed.  Its  capsule  and  usually 
a  thin  layer  of  its  substance  must  be  divided  before  the  nodule 
is  reached.  Hemorrhage  is  readily  controlled  by  clamp  and  liga- 
ture. The  nodule  is  shelled  out  of  its  bed.  The  divided  gland  is 
sutured  with  fine,  catgut  sutures  which  pass  through  its  capsule; 
and  the  deep  fascia  is  similarly  sutured,  while  the  wound  in  the 
skin  is  sutured  with  fine  black  silk.  Only  when  there  is  oozing 
from  the  gland  should  a  small  drain  be  employed. 

The  removal  of  a  part  of  a  diffusely  enlarged  thyroid  gland 
is  a  much  more  serious  matter  and  should  be  undertaken  only  after 
all  precautions  for  a  major  operation  have  been  made,  and  yet 
some  of  the  most  experienced  operators  use  a  local  anesthetic  in 
all  cases  of  goiter.  In  no  case  should  the  whole  gland  be  removed, 
as  myxedema  or  other  nervous  disturbances  are  apt  to  lead  to  a 
speedy  fatality. 

ACQUIRED    DEFORMITIES 

Cicatrices. — Burns  of  the  neck  (p.  125)  are  often  followed 
by  annoying  cicatricial  contractions.  Besides  the  disfigurement 
so  caused,  the  force  of  the  fibrous  bands  may  keep  the  head  twisted 
to  one  side  or  may  bring  the  chin  close  down  to  the  sternum 
(Fig.  87). 

Treatment. — Such  a  condition  of  affairs  may  be  greatly  im- 
proved by  a  suitable  plastic  operation  in  some  cases  and  in  others 
by  extensive  skin-grafting  (Chapter  XX).  If  possible,  the  offend- 
ing bands  should  be  partially  or  wholly  excised,  as  their  presence 
will  seriously  interfere  with  the  result  of  the  operation.  The  exact 
details  of  such  an  operation  cannot  be  given,  as  they  must  be  made 
to  correspond  to  the  necessities  of  each  particular  case.     It  is  well, 

however,  for  both  the  patient  and  the  surgeon  to  recognize  that 
12 


148 


TUMORS   AND   DEFORMITIES   OF   THE   NECK 


the  best  results  under  such  circumstances  are  obtained,  not  by  a 
single  extensive  operation  but  by  several  lesser  ones,  repeated  at 


Fig.  87. — Cicatricial  Contractions  Following  Burn  of  the  Neck. 


intervals  sufficiently  long  to  reveal  the  gain  made  by  each  opera- 
tive attempt. 

Torticollis,  or  "Wryneck. — Wryneck,  or  torticollis,  is  the 
shortening  of  one  or  more  of  the  cervical  muscles,  so  that  the 
head  is  held  in  an  abnormal  position.  There  may  or  may  not 
be  a  spasm  of  these  muscles.  The  sternomastoid  is  the  muscle 
most  affected,  although  the  posterior  cervical  muscles  are  usually 
involved  to  a  certain  extent  (Fig.  88).  The  condition  is  thought 
to  be  due  to  a  unilateral  myositis  of  infancy,  secondary  possibly 
to  traumatism  at  birth,  or  developing  as  one  of  the  lesions  of  con- 
genital syphilis.  As  the  child  grows,  the  lack  of  exercise  of  certain 
muscles  from  the  cramped  position  in  which  the  head  is  con- 
stantly held,  adds  to  the  deformity  and  increases  the  muscular 
changes.     If  nothing  is  done  to  relieve  the  condition,  the  cervical 


TORTICOLLIS,   OR   WRYNECK 


149 


spine  will  become  much  curved,  and  there  vviJl  be  compensatory 
curves  in  both  the  dorsal  and  lumbar  spine.  Even  the  develop- 
ment of  the  head  may  be  affected  (Figs.  89  and  90). 

Strictly  speaking,  cases  of  torticollis  may  be  divided  into  acute 
and  chronic.  Usually,  however,  the  acute  symptoms  will  have 
subsided  before  the  child  is  brought  to  the  doctor. 

Diagnosis. — In  many  cases  the  parent  has  already  recognized 
the  nature  of  the  deformity.  Inspection  shows  that  the  mastoid 
process  on  the  affected  side  is  nearer  to  the  sternum  than  it  should 
be.  This  means  that  the  face  is  turned  toward  the  opposite  side 
and  the  chin  slightly  elevated,  although  the  head  may  be  bent 
toward  the  shoulder  of  the  affected  side.  If  the  contraction  is 
of  long  standing,  the 
whole  head  will  seem 
to  have  slipped  over 
toward  the  unaffected 
side.  This  is  due  to 
the  curvature  of  the 
neck.  But  the  most 
reliable  method  by 
which  to  ascertain 
what  muscles  are  af- 
fected is  to  make  pal- 
pation and  manipula- 
tion of  the  head  and 
neck.  "When  the  head 
is  flexed  and  extended, 
and  abducted  to  the 
right  and  left  and  ro- 
tated, the  difference  in 
the  muscles  of  the  two 
sides  of  the  neck  is  at 
once  apparent.  Such 
manipulation  is  usu- 
ally not  painful  unless 
carried  to  an  extreme 
degree. 

A  differential  diagnosis  between  torticollis  and  tuberculosis  of 
the  cervical  spine  has  sometimes  to  be  made.     In  tuberculosis  there 


Fig.  88. — Wryneck  of  Right  Side  of  Moderate 
Degree.  The  position  of  the  head  is  typical. 
This  patient  was  made  absolutely  straight  by  an 
operation  performed  with  cocain,  and  subsequent 
manipulation. 


150  TUMORS   AND   DEFORMITIES   OF  THE   NECK 

is  extreme  tenderness,  inability  to  move  the  head  in  any  direction 
without  pain,  spasm  of  the  cervical  muscles  when  :in  attempt  is 
made  to  do  so.     Moreover,  there  is  a  daily  sliehl   lexer. 


Fig.  89. — Extreme  Degree  of  Torticollis,  said  by  Patient  to  be  Congenital. 
Note  the  deformity  of  face,  as  well  as  of  spine.  The  ulcer  of  the  nose  was  due 
to  recent  traumatism. 

Treatment. — The  first  treatment  of  acute  torticollis  is  the 
treatment  of  the  traumatism  or  acute  myositis  in  which  it  origi- 
nates.    This  consists  in  the  application  of  heat,  and  the  mainte- 


Fig.  90. — Back  View  of  Same  Patient. 


TORTICOLLIS,   OR   WRYNECK  151 

nance  of  the  head  in  a  correct  position,  or  at  least  the  prevention  of 
an  increase  in  the  deformity.  If  the  condition  is  considered  to 
be  rheumatic,  salicylate  of  soda  should  be  administered. 

As  soon  as  the  pain  subsides,  treatment  by  manipulation  should 
be  commenced  to  correct  existing  deformity.  The  effort  should  be 
to  overcorrect  the  deformity  which  exists.  Therefore  the  face  should 
be  rotated  in  the  opposite  direction  until  the  affected  sternomas- 
toid  is  tight.  The  chin  should  then  be  tilted  downward  and  the 
head  bent  away  from  the  affected  shoulder.  These  manipulations 
should  be  made  a  number  of  times-,  and  the  treatment  repeated 
each  day  until  the  deformity  is  overcome.  Even  then  it  is  better 
for  the  physician  to  see  the  child  once  a  week  for  a  few  weeks. 

If  the  patient  is  an  infant,  manipulation  described  may  be 
carried  out  upon  the  mother's  lap.  If  it  is  an  older  child,  it 
should  sit  upright  during  the  treatment.  In  either  case  it  is  an 
advantage  if  a  second  person  holds  the  shoulders  while  the  ma- 
nipulations are  made,  so  that  the  manipulator  can  make  traction 
upon  the  head  while  twisting  it  and  bending  it. 

During  sleep  the  pillow  should  be  so  arranged  that  the  position 
of  the  body  will  tend  to  correct  the  deformity,  or  at  least  will  not 
tend  to  increase  it. 

In  chronic  cases,  treatment  by  manipulation  will  succeed  only 
if  the  affected  muscles  are  still  elastic ;  otherwise  operative  treat- 
ment is  indicated.  In  slight  cases,  division  of  the  sternomastoid 
muscle  is  necessary,  whereas  in  the  severer  cases  the  trapezius  sple- 
nitis and  other  muscles  will  also  require  division. 

The  incision  may  be  made  parallel  to  the  edge  of  the  sterno- 
mastoid or  parallel  to  the  clavicle.  The  former  leaves  a  slighter 
scar.  The  incision  should  be  at  least  an  inch  long.  Usually, 
when  the  most  prominent  bands  have  been  divided  and  tension 
has  separated  their  cut  ends,  it  will  be  found  that  other  deeper  ones 
still  hold  the  head  to  a  lesser  degree  in  an  abnormal  position. 
Such  bands  should  in  turn  be  divided  until  motion  of  the  head 
is  free.  The  restraining  muscular  bands  lie  a  little  outside  the 
sheath  of  the  great  vessels,  and  the  latter  could  be  injured  only 
by  careless  cutting.  ISTo  deep  suture  is  necessary.  Hemorrhage 
should  be  stopped  and  the  skin-wound  entirely  closed  with  fine 
black  silk  sutures.  A  firm  dressing  should  be  applied,  and  the 
head  put  up  in  an  overcorrected  position  and  held  so  by  a  plaster 


152  TUMORS  AND   DEFORMITIES   OF   THE   NECK 

of  Paris  bandage  placed  around  the  neck,  over  the  head,  and  under 
both  arms  I  X".  22,  Chapter  XXI  |.  If  there  is  no  rise  of  tem- 
perature or  pain,  the  dressing  need  not  lie  changed  for  a  week  or 
ten  davs.  As  soon  as  the  wound  has  healed,  gentle  passive  rota- 
tion and  other  motions  of  the  head  should  be  commenced  and 
repeated  every  other  day  for  several  weeks.  As  time  goes  on, 
the  force  with  which  this  is  done  may  be  increased,  and  in  addition 
the  patienl  should  practise  active  motion  daily  to  correct  the  de- 
formity and  increase  the  mobility  of  the  neck.  The  best  single 
exercise  thai  the  patienl  can  make  is  the  following:  Stand  erect; 
turn  the  chin  toward  the  affected  side,  without  lifting  it;  incline 
the  head  toward  the  shoulder  of  the  unaffected  side,  while  the  face 
is  still  turned  inward  the  other  side;  place  the  head  erect.  This 
exercise  should  be  repented  several  times  morning,  noon,  and  night. 
At  firs!  the  patient  should  go  through  the  exercise  in  the  physi- 
cian's presence,  as  he  will  otherwise  almost  certainly  fail  to  make 
the  motions  correctly. 


SECTION  III 
AFFECTIONS  OF  THE  TRUNK 


CHAPTER    VI 
INJURIES    AND    INFLAMMATIONS   OF    THE   TRUNK 

INJURIES 

Contusions  of  the  Chest  and  Back. — Blows  upon  the 
chest  and  back  on  account  of  the  firm  underlying  bones  usually 
produce  little  injury.  General  directions  for  treatment  of  such 
injuries  are  given  on  page  2. 

Contusion  of  the  Breast. — A  blow  on  the  mammary  gland  may 
produce  a  partial  rupture  with  the  formation  of  a  hematoma  (Fig. 


Fig.  91. — Large  Hematoma  of  Mammary  Region,  Five  Weeks  After  a  Blow. 

91 ;  see  p.  3  for  treatment)  or  an  inflammation,  mastitis,  or 
even  abscess.  It  may  also  be  followed  by  a  malignant  growth. 
Hence  the  importance  of  immediate  intelligent  treatment. 

153 


154  INJURIES    AND    INFLAMMATIONS   OF   THE   TRUNK 

Hot,  moisl  applications  should  be  applied  to  the  breast,  or  the 
surface  may  be  covered  with  gauze  thickly  spread  with  ichthyol 
ointment,  and  outside  of  this  a  layer  of  non-absorbent  cotton  or 
lamb's  wool.  Moderate,  even  pressure  is  to  be  maintained  by  a 
breast  bandage,  which  should  be  so  applied  that  the  breast  is  sup- 
ported from  the  shoulder  (  No.  l's.  Chapter  XXI).  After  a  few 
days  gentle  massage  should  be  administered. 

Contusion  of  the  Back  and  Ribs. — Contusion  of  the  back  is  con- 
sidered under  the  beading  Sprain  (p.  158),  and  contusion  of  a 
rib  under  the  heading  Fracture  (p.   L67). 

Contusion  of  the  Abdomen. — Blows  or  undue  pressure 
upon  the  abdomen  are  important  less  for  their  effect  upon  the 
abdominal  wall  than  upon  the  abdominal  organs,  one  or  more  of 
which  may  be  ruptured  or  seriously  injured  by  violence  which 
leaves  no  mark  upon  the  skin. 

A  sharp  unexpected  blow  upon  the  abdomen  is  apt  to  produce 
a  condition  of  shock  which  is  familiar  to  every  boy  under  the 
phrase  "  it  knocked  the  wind  out  of  him."  The  abdominal  muscles 
being  off  their  guard,  the  force  of  the  blow  is  received  upon  the 
sensitive  structures  beneath,  especially  upon  the  sympathetic  gan- 
glia in  the  region  of  the  solar  plexus,  and  faintness  and  nausea 
and  possibly  vomiting  and  unconsciousness  follow.  Such  a  blow 
may  even  produce  death,  although  this  is  not  common  in  an  animal 
the  size  of  man.  When  the  muscles  are  forewarned  and  have  time 
to  contract,  they  can  protect  the  abdominal  organs  against  a  very 
heavy  pressure.  For  instance,  a  man  weighing,  say,  170  pounds, 
can  lie  face  downward  bearing  his  whole  weight  on  a  horizontal 
bar  which  crosses  his  abdomen.  The  rigidity  of  the  recti  and  other 
muscles  prevents  the  bar  from  pressing  backward  enough  to  pinch 
the  intestine  or  mesentery  against  the  spinal  column.  This  ex- 
plains how  so  many  persons  escape  serious  injury  from  the  wheel 
of  a  moving  vehicle,  even  though  it  passes  directly  across  the 
abdomen.  Such  escapes  have  been  frequently  noted,  even  when 
the  vehicle  has  weighed  more  than  3,000  pounds  (750  pounds 
weight  on  each  of  four  wheels).  When  the  wheel  is  broad  and 
rubber-tired,  the  possibility  of  escape  from  serious  injury  is  natu- 
rally much  greater  than  with  a  wheel  having  a  narrow  steel  tire. 

Diagnosis. — The  principal  symptoms  of  contusion  of  the  abdo- 
men are  general.    They  are  the  symptoms  which,  grouped  together, 


CONTUSIONS   OF  THE  ABDOMEN  155 

are  spoken  of  as  shock — namely,  feeble  pulse,  pallor,  cold,  pos- 
sibly clammy  skin,  and  frequent  respiration.  These  are  also  the 
symptoms  of  internal  hemorrhage  and  of  rupture  of  the  stomach 
or  intestine,  which  are  often  the  result  of  undue  force  applied  to 
the  abdomen.  It  is  important  to  separate  simple  contusion  from 
these  other  conditions,  if  possible,  since  their  respective  treatments 
are  opposites.  Often  the  progress  of  the  case  will  alone  decide.  If 
there  is  uncomplicated  contusion,  the  symptoms  will  rapidly  dis- 
appear. If  there  is  an  accompanying  internal  hemorrhage  or  rup- 
ture, the  pulse  and  respiration  will  increase  in  rate,  the  patient 
will  become  more  restless,  and  the  symptoms  of  shock  will  become 
more  marked.  Vomiting  usually  accompanies  rupture  of  an  intra- 
abdominal organ.  The  vomitus  should  be  examined  microscopi- 
cally to  determine  the  possible  presence  of  blood. 

There  is  usually  pain  at  the  seat  of  rupture,  extending  thence 
in  the  direction  in  which  the  escaped  intestinal  contents  would  be 
likely  to  gravitate.  If  the  amount  of  escaped  fluid  is  large,  its 
presence  as  free  abdominal  fluid  may  be  shown  by  percussion  with 
the  patient  lying  first  on  his  back  and  then  on  his  side,  or  in 
other  positions.  Abdominal  rigidity  on  palpation  is  a  sign  of  great 
importance.  It  may  exist  in  simple  contusion,  but  it  is  less 
marked  than  it  is  in  more  serious  conditions  and  tends  to  de- 
crease. 

In  all  cases  of  abdominal  injury  the  whole  abdomen  should  be 
carefully  examined  with  the  stethoscope.  By  this  means  one  can 
determine  whether  the  normal  peristaltic  action  of  the  intestines 
is  going  on,  whether  normal  peristalsis  is  at  a  standstill,  and, 
roughly,  the  shape  of  the  air-spaces  which  distend  the  abdomen, 
and  the  presence  of  free  fluid  or  gas.  All  of  these  factors  have  their 
weight  in  determining  the  question  of  operation.  If  perforation  of 
stomach  or  intestines  is  present,  immediate  operation  and  suture 
gives  the  patient  the  only  chance  of  recovery.  Under  such  circum- 
stances the  delay  of  a  few  hours  will  reduce  such  chance  by  at 
least  one-half,  as  the  successful  cases  are  almost  exclusively  those 
operated  upon  within  sixteen  or  twenty-four  hours  after  the  acci- 
dent. The  character  of  the  urine,  and  the  patient's  ability  to 
pass  it,  and  the  state  of  the  bowels  must  also  be  considered,  as 
rupture  of  the  bladder  or  of  one  kidney  is  as  urgent  an  indication 
for  operation  as  is  that  of  the  stomach  or  intestines. 


156  tNJURlES   AND   INFLAMMATIONS  OF  THE  TRUNK 

Non-operative  Treatment.- — If  it  is  decided  that  no  serious 
interna]  injury  exists,  and  in  all  cases,  before  a  complete  diagnosis 
can  be  made,  the  patient  should  be  kept  absolutely  quiet  in  a  hori- 
zontal position.  An  ice-bag  or  heal  applied  to  the  abdomen  usu- 
ally helps  n.ward  this  end.  It  is  desirable  to  avoid  morphine  until 
the  diagnosis  is  clear.  If  this  is  not  possible,  the  doses  given 
should  be  small,  and  should  be  administered  hypodermically.  Ab- 
solutely uothing  should  be  given  by  mouth.  If  the  skin  is  broken 
a  light,  moist,  antiseptic  dressing  should  be  applied.  The  symp- 
toms of  the  patient  should  be  noted  every  hour.  If  they  all  im- 
prove steadily,  it  may  be  safely  inferred  that  there  is  a  simple 
contusion.  If  ihe_\  -row  worse,  and  particularly  if  local  muscular 
rigidity  is  noted  or  increases,  laparotomy  should  be  performed. 
It  should  be  the  aim  of  the  surgeon  to  decide  definitely  for  or 
against  operation  in  less  than  twelve  hours  from  the  injury.  This 
gives  the  patient  the  best  chance  of  recovery  after  operation,  what- 
ever the  character  of  the  injury. 

If  the  contusion  is  uncomplicated,  the  patient  may  be  allowed 
water  after  twelve  hours,  fluid  nourishment  on  the  following  day, 
and  solid  food  after  the  bowels  have  been  moved. 

It  is  well  worth  remembering  that  a  contusion  of  the  abdomi- 
nal wall  may  be  accompanied  by  a  contusion  of  the  intestine  with- 
out immediate  hemorrhage  or  rupture.  This  is  particularly  apt 
to  be  the  case  after  wheel  injury.  The  slough  of  intestine  may 
give  way  and  allow  the  intestinal  contents  to  escape  into  the  abdo- 
men as  late  as  two  weeks  after  the  injury.  The  warning  sign  is 
a  localized  contraction  of  the  muscles  of  the  abdominal  wall.  The 
patient  should  be  kept  in  bed  and  on  the  simplest  fluid  diet  until 
this  disappears. 

Wounds. — Uncomplicated  wounds  of  the  trunk  should  be 
treated  in  accordance  with  the  rules  given  on  page  13. 

Hemorrhage  from  the  Umbilicus. — This  occurs  in  the  infant, 
due  to  premature  separation  of  the  cord.  The  hemorrhage  should 
be  controlled  by  solution  of  adrenalin  (1:  2,000)  and  pressure,  or 
by  application  of  peroxide  of  hydrogen  full  strength  or  diluted 
one-half,  or  if  necessary  by  ligature.  Asepsis  should  be  observed 
in  the  dressing. 

Gunshot  Wound  of  the  Back.— Gunshot  wound  of  the  back 
as  met  with  in  civil  life  is  frequently  not  serious,  as  the  bullets 


WOUNDS  157 

of  small  caliber  fired  from  cheap  revolvers  do  not  ponctrnte  through 
the  thick  muscles  in  this  region.  A  bullet  fired  into  the  back  may 
be  deflected  by  the  strong  fascial  planes  or  by  some  vertebra;  it 
is  therefore  difficult  to  make  out  its  exact  location  or  to  follow 
its  track  with  the  probe.  Unless  its  situation  is  easily  determin- 
able, the  surgeon  should  recognize  that  the  operation  for  its  re- 
moval may  be  a  protracted  one,  and  should  make  preparation 
accordingly.  If  the  bullet  is  within  easy  reach  it  may  be  extracted 
and  the  wound  properly  treated  without  a  general  anesthetic.  The 
position  of  the  bullet  may  be  shown  in  a  radiograph  if  the  patient 
is  not  too  stout. 

Penetrating  Wound  of  the  Pleural  Cavity. — A .  bullet  or  the 
point  of  a  knife  may  pass  between  two  ribs  and  open  the  pleural 
cavity.  Air  or  blood  may  then  occupy  the  pleural  space.  There 
may  be  more  or  less  shock.  If  there  is  no  wound  of  exit,  an  at- 
tempt should  be  made  to  locate  the  bullet  by  means  of  the  X-ray. 
If  the  lung  is  injured  there  is  usually  a  certain  amount  of  cough 
and  hemoptysis  and  an  effusion  of  blood  into  the  pleural  cavity, 
revealed  by  an  area  of  dulness  on  percussion ;  but  even  these  symp- 
toms may  be  very  slight.  If  a  large  artery  is  broken,  death  fol- 
lows rapidly,  partly  from  hemorrhage  and  partly  from  suffocation, 
as  the  blood  which  pours  into  the  bronchi  is  imperfectly  coughed 
out. 

Treatment. — -Air  or  a  small  quantity  of  blood  is  readily  re- 
sorbed  from  the  healthy  pleural  cavity.  Even  a  foreign  body 
such  as  a  bullet  may  give  no  trouble.  It  is  best,  therefore,  not  to 
explore  a  penetrating  wound  of  the  chest  unless  there  is  some 
definite  reason  for  interference,  such  as  the  known  accessibility  of 
the  bullet,  continued  hemorrhage,  or  the  existence  of  suppuration 
(p.  175).  Drainage  is  secured  by  the  resection  of  two  inches  of 
one  rib  as  described  on  page  177. 

Penetrating  Wound  of  the  Pericardial  Cavity — A  penetrating- 
wound  of  the  pericardium  alone  may  be  sutured  under  cocain 
after  the  excision  of  an  inch  or  two  of  one  rib,  or  the  wound  may 
be  left  to  unite  of  itself.  The  danger  in  such  a  case  is  not  from 
the  extent  of  the  injury,  but  from  the  possibility  of  subsequent  in- 
flammation. Drainage  is  inadvisable  in  a  recent  case,  but  if  pus 
forms  in  the  sac,  extensive  drainage  will  of  course  be  required. 
If  the  heart  is  injured  the  case  is  by  no  means  hopeless.    Instances 


158  INJURIES  AND   INFLAMMATIONS   OF  THE  TRUNK 

are  on  record  in  which  after  the  resection  of  a  portion  of  one  or 
more  ribs,  the  pericardial  sac  has  been  opened  and  the  wound 
in  the  heart  successfully  closed  by  suture. 

Penetrating  Wound  of  the  Abdomen. — Every  wound  of  the  ab- 
domen shoujd  be  explored  until  the  surgeon  can  either  see  its  bot- 
tom or  can  assure  himself  that  it  has  entered  the  abdominal  cav- 
ity. Whether  it  should  be  explored  still  further  will  depend  on 
circumstances.  It  is  generally  agreed  that  the  abdomen  should  be 
opened  after  every  gunshot  wound,  and  after  every  stab  wound  ac- 
companied by  symptoms  of  hemorrhage  or  intestinal  injury.  As  to 
penetrating  wounds  without  symptoms  of  complication,  it  may  be 
said  that  the  risk  of  opening  the  abdomen  with  suitable  facilities 
is  less  than  the  risk  of  allowing  the  injury  to  go  without  explora- 
tion.    The  younger  surgeons  at  least  are  acting  on  this  principle. 

Sprains. — Sprain  of  Back. — As  a  result  of  twists  and  falls, 
and  less  often  of  blows,  the  back  is  sprained,  almost  always  at  the 
junction  of  the  lumbar  and  sacral  regions.  Often  under  such  cir- 
cumstances there  is  little  or  no  change  in  its  appearance;  the  usual 
symptoms  are  those  of  stiffness,  and  pain  at  the  pelvic  attachment 
of  one  or  both  lumbosacral  muscles,  noticed  especially  when  the 
position  is  changed  after  a  short  period  of  quiet  or  when  an 
attempt  is  made  to  bend  the  body  in  certain  directions.  Some- 
times it  is  almost  impossible  to  stand  erect.  In  the  simpler  cases 
the  symptoms  are  due  to  stretching  or  bruising  of  the  muscles  or 
of  the  intermuscular  cellular  tissue.  In  the  severer  cases  it  is 
probable  that  some  of  the  muscular  or  fibrous  threads  are  broken ; 
at  any  rate,  the  symptoms  often  persist  for  a  provokingly  long 
period,  sometimes  for  several  weeks. 

It  is  not  always  possible  to  differentiate  a  sprain  of  the  back 
from  lumbago.  The  latter  is  technically  a  neuralgia  in  the  mus- 
cles of  the  back,  and  usually  comes  on  after  exposure  to  cold.  If 
such  exposure  is  combined  with  overexertion  it  may  be  impossible 
to  tell  whether  the  symptoms  are  due  to  sprain  or  to  lumbago.  As 
the  treatment  is  similar  in  some  respects,  the  doubt  is  less  impor- 
tant than  it  would  be  otherwise. 

Treatment. — The  first  indication  for  treatment  is  the  relief 
of  the  pain.  This  may  be  constant,  or  occur  only  when  the  mus- 
cles of  the  back  are  contracted.  There  may  be  a  partial  spasm  of 
the  muscles  which  greatly  aggravates  the  pain.     The  patient  should 


SPRAINS  1 59 

remain  in  bed  while  the  symptoms  are  acute,  and  external  heat 
should  he  applied.  This  may  be  moist  or  dry.  A  hot-water  bag 
filled  with  boiling  water  is  a  convenient  form  of  iipplirnlion.  Hot 
moist  compresses  may  be  applied,  covered  with  flannel,  and  still 
further  heated  by  a  flat-iron. 

Massage  is  indicated,  especially  around  the  origin  of  the 
strong  muscles  of  the  back  from  the  sacrum  and  ileum.  The 
massage  to  be  effectual  must  be  given  with  a  good  deal  of  force; 
hence  mechanical  vibration  with  a  good  machine  is  most  service- 
able in  these  cases. 

Dry-cupping  is  another  means  of  relieving  pain  in  this  region 
which  is  not  used  nearly  as  often  as  it  should  be. 

The  various  counter-irritants  may  be  employed.  No  one  is 
better,  and  none  so  cleanly,  as  the  thermocautery.  The  point  of 
the  cautery,  preferably  a  round  one,  should  be  kept  at  a  pale  red 
heat,  and  should  be  swung  in  circles  which  just  touch  the  back 
tangentially.  In  this  manner  the  cauterization  can  be  performed 
with  a  delicacy  quite  impossible  if  a  forward  and  backward 
movement  be  given  to  the  point.  The  pain  of  this  treatment  is 
very  slight  if  the  point  passes  swiftly  over  the  skin,  so.  that  the 
cauterization  can  be  continued  until  the  whole  painful  area  has 
been  thoroughly  gone  over.  The  treatment  may  be  repeated  the 
following  day,  if  necessary.  Sometimes  a  single  application  will 
effect  a  cure. 

It  is  rarely  necessary  to  give  morphin.  Acetanilid,  or  one 
of  the  other  coal-tar  products,  is  sufficiently  powerful  if  an  anal- 
gesic is  necessary. 

There  is  one  other  remedy  which  is  said  to  stop  the  pain  in 
lumbago  almost  instantly,  and  that  is  the  injection  of  from  four 
to  twelve  ounces  of  sterile  normal  salt  solution  into  the  muscles 
of  the  back. 

In  cases  of  sprain  it  is  important  to  support  the  back  and  to 
keep  the  injured  parts  at  rest.  For  this  purpose  a  proper  strap- 
ping with  adhesive  plaster  is  excellent.  The  use  of  a  porous  plas- 
ter is  too  well  known  to  require  mention.  A  far  more  efficient 
support  can  be  obtained  as  follows:  two  strips  of  adhesive,  three 
inches  broad,  are  applied  on  either  side  of  the  spine  from  the 
lower  angle  of  the  scapula  nearly  to  the  tuberosities  of  the  ischia. 
There  should  be  a  space  of  a  half  inch  between  them.     Six  trans- 


160 


INJURIES  AND  INFLAMMATIONS  OF  THE  TRUNK 


verse  strips,  each  two  inches  broad,  and  long  enough  to  reach  a 
little  more  than  half-way  around  the  body,  should  cross  these  ver- 
tical  strips  at    righl   angles   (Fig.  92).     There  should  be  a  space 


Fig.  92. — Strips  of  Adhesive  Plaster 
Applied  to  Give  Support  to  a 
Sprained  Back;  Gridiron  Strap- 
pint:. 


Fig.  93. — Strips  of  Adhesive  Plaster 
Applied  Diagonally  to  Give  Sup- 
port to  a  Sprained  Back. 


of  hall  i.ii  inch  to  an  inch  between  each  one  of  these  to  allow  the 
perspiration  to  evaporate  and  to  lessen  the  itching  which  follows 
the  application  of  a  broad,  unventilated  strip  of  adhesive  plaster. 

Another  method  of  strapping  is  to  apply  the  strips  of  adhesive 
plaster  diagonally.  It  is  easier  to  make  the  plaster  fit  a  hollow 
back  when  it  is  applied  in  this  manner  (Fig.  93). 

Whatever  the  method  of  strapping  chosen,  the  patient  should 
stand  upright  or  lie  prone  on  his  face  when  the  strips  are  applied, 
so  that  the  back  may  be  fully  extended  at  the  time.     He  should 


SPRAINS 


161 


subsequently  avoid  bending  forward,  as  that  loosens  the  plaster 
and  lessens  its  usefulness.  The  strapping  should  be  repeated  every 
two  or  three  days,  or  as  often  as  it  loosens.  The  old  plaster  can 
be  peeled  off,  or  washed  off  with  ether  or  benzin  or  "  carbona." 

In  some  cases  the  administration  of  the  salicylates  seems  to 
hasten  recovery.     This  is  especially  true  in  cases  of  lumbago. 

Eailroad  Spine. — The  effects  of  a  severe  contusion  of  the  back 
or  sprain  of  the  spinal  column  are  sometimes  felt  for  months  or 
years.  It  is  important  for  the  surgeon  to  know  whether  the  symp- 
toms complained  of  are  real  or  are  kept  in  the  mind  of  the  patient 
by  an  expected  suit  for  damages.     This  doubt  has  earned  for  this 


Fig.  94. — Tests  for  Injury  of  the 
Spine.  The  patient  bends  forward. 
Note  the  full  normal  curve  of  the 
spine. 


Fig.  95.  —  Tests  for  Injury  of  the 
Spine.  The  patient  bends  backward. 
Note  the  concavity  of  the  dorsolum- 
bar  region.  This  attitude  is  impos- 
sible in  sprain. 


type  of  injury  the  name  "  railroad  spine."  Without  going  into 
the  remote  details  of  this  subject,  it  is  worth  while  emphasizing 
one  point.    Whoever  examines  one  of  these  patients  should  inspect 


162 


INJURIES    AXD    INFLAMMATIONS    OF   THE   TRUNK 


and  palpate  the  back  from  the  skull  to  the  sacrum,  and  should 
then  test  the  functions  of  the  spine  in  the  following  manner:  The 
patient  should  he  stripped  to  the  hips  and  stand  erect  with  Ids 
back  toward  the  surgeon.  1.  lie  should  bend  forward  and  back- 
ward several  times,  keeping  the  knees  straight,  while  the  surgeon 
notes  the  flexibility  of  the  different  portions  of  the  spine  (Figs. 
94  and  95).     If  any  portion  has  been   injured   the  muscles  will 


Fig.  96. — Tests  for  In  jury  of  the  Spine.  Fig.    97. — Tests    for    Injury    of    the 

The  patient  bends   to   the  left,  keep-  Spine.   The  patient  twists  to  the  right 

ing  the  knees  straight.     The  same  mo-  and  then  to  the  left  without  moving 

tion  should  be  made  to  the  right.  the  feet. 

hold  it  rigid  while  the  other  parts  are  bending.  This  is  especially 
striking  if  one  side  is  involved  more  than  the  other.  This  con- 
traction of  a  part  of  the  muscles  of  the  back  is  something  which 
cannot  be  imitated,  and  if  present  represents  real  injury.  2.  The 
patient  stands  erect  as  before,  and  then,  without  flexing  the  knees, 
he  bends  his  body  toward  the  right  and  then  toward  the  left,  while 
the  range  of  motion  of  the  spine  and  possible  irregular  muscular 
action  is  noted  as  before  (Fig.  96).     3.   The  patient,  without  mov- 


FRACTURES 


163 


ing  his  feet  on  the  floor,  twists  his  shoulders  around  to  the  right 
as  far  as  possible,  and  then  around  to  the  left  (Fig.  97).  The 
limit  of  motion  in  these  various  directions,  and  any  other  points 
observed,  should  be  recorded  for  future  comparison. 

Treatment. — The  treatment  in  these  cases  must  be  long  con- 
tinued to  produce  permanent  results  If  tenderness  is  marked,  the 
spine  should  be  supported  by  a  plaster  of  Paris  jacket  (Chapter 
XXII).  In  most  cases  it  is  better  to  obtain  the  support  by  a  re- 
movable corset,  so  that  there  may  be  daily  massage  and.  exercises. 
Mechanical  vibration  is  of  great  service.  Out-of-door  life  and 
other  hygienic  measures  are  of  the  greatest  importance.  There 
is  a  strong  tendency  to  hysteria  in  these  patients,  and  the  regu- 
lation of  the  daily  life  should  be  such  as  will  lessen  rather  than 
increase  this  tendency. 

Fractures. — Fracture  of  Clavicle. — Sometimes  by  direct  vio- 
lence, or  more  often  as  a  result  of  falls  upon  the  arm  or  shoulder, 


Fig.  98. — Fracture  of  Left  Clavicle  in  the  Usual  Situation  of  one  Week's 

Duration. 


the  clavicle  is  fractured.  Any  portion  of  the  bone  may  be  broken, 
but  the  line  of  fracture  is  in  the  great  majority  of  instances  within 
an  inch  of  the  center  of  the  bone  (Fig.  98).  The  normal  outline 
is  changed,  due  to  edema  and  the  irregularity  of  the  broken  bone. 
The  amount  of  deformity  varies  greatly.  The  line  of  fracture 
13 


164  INJURIES   AND   INFLAMMATIONS   OF  THE   TRUNK 

is  usually  an  oblique  one,  and  either  the  outer  or  inner  fragment 
is  displaced  backward. 

There  is  more  or  less  disability  of  the  arm,  extreme  motions 
being-  limited  by  pain.  In  some  cases  measuremenl  from  the  ster- 
nal to  the  scapular  end  of  the  bone  will  show  a  shortening,  but  this 
is  not  always  the  case.  There  is  a  swelling  and  tenderness  at  the 
site  of  fracture,  and  crepitus  can  usually  be  obtained,  unless  the 
fracture  is  near  the  outer  extremity  of  the  bone.  In  that  case 
motion  between  the  fragments  may  be  prevented  by  the  various 
ligamentous  attachments  to  the  coracoid  and  acromion  processes. 
Ecchyrnosis  is  usually  present,  but  is  often  slight. 

Treatment. — On  account  of  the  impossibility  of  applying  any 
form  of  apparatus  on  both  sides  of  the  bone,  treatment  of  a  frac- 
tured clavicle,  aiming  to  reduce  the  misplaced  fragments  and  to 
keep  them  in  position,  is  eminently  unsatisfactory.  'This  docs  not 
mean  that  a  bad  result  is  to  be  anticipated.  On  the  contrary,  in 
most  cases  the  bone  unites  speedily,  with  little  deformity,  if  the 
arm  is  merely  kept  in  a  sling.  Many  times  some  child's  mother 
has  brought  it  for  treatment  two  weeks  or  more  after  the  fall 
occurred,  with  not  the  slightest  idea  that  any  bone  had  been 
broken.  The  pain  disappeared  a  day  or  two  after  the  accident, 
and  she  only  sought  medical  advice  on  account  of  the  slight  swell- 
ing at  the  seat  of  fracture,  or  because  the  child  still  cried  when 
lifted  by  that  arm.  In  these  absolutely  untreated  cases  there  is 
often  union  with  a  minimum  of  deformity. 

If  no  deformity  exists,  or  if  it  is  slight,  the  patient  should 
not  be  tortured  with  unnecessary  apparatus.  The  arm  should 
merely  be  supported  in  a  sling,  or  if  the  patient  is  restless,  or  is 
a  child,  a  simple  bandage  of  the  arm  to  the  chest  should  be  applied. 
A  good  bandage  for  this  purpose  is  the  Velpeau  (Xo.  30,  Chapter 
XXI).  This  method  of  treatment  is  adapted  not  only  to  fracture 
of  the  outer  portion  of  the  clavicle,  but  to  many  fractures  in  the 
central  portion.  Sometimes  existing  deformity  may  be  lessened  by 
pressure  directly  upon  the  projecting  fragment,  obtained  by  a  com- 
press of  gauze  and  two  strips  of  adhesive  plaster  crossed  over  it 
in  an  X.  This  is  only  advisable  in  those  cases  in  which  slight 
digital  pressure  has  been  found  efficacious  in  replacing  a  fragment. 

There  remain  for  consideration  those  cases  in  which  deformity 
is  considerable.     The  fracture  is  usually  oblique  and  the  fragments 


FRACTURES 


165 


have  overlapped.  If  the  fracture  is  recent,  one  car  usually  reduce 
the  overlapping  by  grasping  I  lie  upper  part  of  I  lie  arm  and  pulling 
the  shoulder  outward  and  backward.  But  while  this  can  be  accom- 
plished manually,  and  for  a  few  minutes  without  pain,  attempts 
to  keep  up  this  extension  for  two  or  three  weeks  are  sometimes 
very  painful,  so  that  the  patient  wriggles  until  the  pull  is  less- 
ened, or,  if  he  fails  to  do  so,  the  skin  where  pressure  is  greatest 
may  become  excoriated.  I  have  repeatedly  seen  instances  of  this 
in  cases  in  which  a  Sayre's  dressing  has  been  applied. 

Extension  upon  the  Principle  of  the  Lever. — There  are  two 
ways  in  which  the  shoulder  may  be  pried  out  and  backward  by 
means  of  bandages  alone.  A  pad  may  be  placed  in  the  axilla,  and 
upon  this  as  a  fulcrum  the  humerus  may  be  used  as  a  lever.  When 
the  elbow  is  brought  to  the  side  the  shoulder  is  pried  outward. 
This  is  the  principle  of  the  antiquated  Desault  bandage  (Xo.  31, 


Fig.  99. — Sayre  Dressing  for  Frac- 
ture of  Clavicle.  Rear  view.  Show- 
ing application  of  first  strip  of  adhe- 
sive plaster. 


Fig.  100. — Sayre  Dressing  for  Frac- 
ture of  Clavicle.  Front  view. 
Showing  application  of  second  strip 
of  adhesive  plaster. 


Chapter  XXI).  Gradual  flattening  of  the  pad  relieves  the  patient 
and  does  away  with  the  extension  upon  the  clavicle.  The  other 
method  is  that  of  the  Sayre  dressing  and  the  Moore  bandage.  In  the 
Sayre  dressing  the  upper  part  of  the  humerus  is  fixed  well  back- 


166  INJURIES    AND    INFLAMMATIONS   OF   THE   TRUNK 

ward  by  a  loop  of  adhesive  plaster  about  the  arm  and  a  continua- 
tion of  the  same  around  the  back  and  side  of  the  chest,  until  it 
is  fastened  to  itself.  The  elbow  is  then  pulled  well  forward  and 
fixed  by  a  second  strip  of  adhesive  plaster.  The  first  loop  acts 
as  a  fulcrum  and  the  shoulder  is  carried  backward  (Figs.  99  and 
100). 

Moore's  bandage  acts  on  a  similar  principle,  by  pushing  up- 
ward the  shoulder  and  drawing  backward  the  arm  by  means  of  a 
strip  of  cotton  cloth  twisted  around  the  elbow  in  two  directions. 

Direct  Extension  hi/  Mams  of  Rigid  Apparatus. — If  a  prop- 
erly padded  splint  is  placed  across  the  back  of  the  shoulders  they 
may  be  bandaged  or  strapped  to  it,  and  thus  extension  of  a  broken 
clavicle  be  obtained  with  a  minimum  of  pressure  upon  the  soft 
parts.  A  board  used  for  this  purpose  is  likely  to  slip  unless  it 
is  fixed  by  an  upright  piece.  This  makes  a  veritable  cross,  and 
few  patients  will  consent  to  be  bound  to  snch  an  apparatus  for 
two  or  three  weeks.  It  is,  however,  very  efficient  in  reducing  de- 
formity to  a  minimum. 

Another  plan  which  often  succeeds  is  the  application  of  the 
posterior  figure  of  eight  bandage  of  the  chest  (ISTo.  26,  Chapter 
XXI)  in  plaster  of  Paris.  The  bandage  should  be  reenforced  with 
a  molded  strip  across  the  back  of  the  shoulders,  or  a  light  wooden 
splint  may  be  incorporated  in  it. 

Reduction  hy  Operation. — Of  course  none  of  the  methods  of 
extension  above  described  is  applicable  unless  reduction  can  be 
accomplished  manually  without  the  employment  of  much  force. 
In  other  cases,  unless  one  is  willing  to  allow  union  to  take  place 
with  deformity,  it  will  be  necessary  to  make  an  incision  over  the 
site  of  fracture  to  bring  the  ends  of  the  bone  into  a  correct  posi- 
tion, and  to  keep  them  there  by  means  of  a  suture  of  chromicized 
catgut  or  kangaroo  tendon.  It  may  seem  like  an  unwarrantable 
procedure  to  convert  a  simple  into  a  compound  fracture,  but  in 
the  experience  of  the  writer  the  result  obtained  often  justifies  the 
operation,  as  the  bone  will  unite  without  deformity,  and  the  scar 
in  a  few  weeks  can  scarcely  be  made  out.  Such  an  operation  can 
be  performed  with  cocain  if  the  patient  is  old  enough  to  appre- 
ciate the  advantages  of  local  anesthesia.  The  suture  material  em- 
ployed should  be  capable  of  resisting  disintegration  for  at  least 
four  weeks. 


FRACTURES  167 

Fracture  of  the  scapula  is  far  less  common  than  that  of  the 
clavicle.  If  the  fracture  is  of  the  body  of  the  scapula  or  of  its 
acromion  process  it  is  easily  made  out,  crepitus  usually  being  ob- 
tained by  direct  manipulation.  ISTo  treatment  is  required  other 
than  limitation  of  the  motion  of  the  arm.  Fracture  of  the  neck 
of  the  scapula  is  a  rare  accident,  whose  exact  diagnosis,  like  that 
of  other  fractures  about  joints,  is  most  surely  made  by  a  good 
radiograph.  The  arm  should  be  kept  at  rest  for  four  or  six  weeks 
by  a  shoulder  cap  and  sling  (cf.  No.  34,  Chapter  XXI). 

Fracture  of  Sternum. — A  severe  blow  is  required  to  break  the 
sternum.  Even  if  this  occurs,  displacement  of  the  fragments  is 
unlikely.  So  that  diagnosis  depends  upon  the  history,  tenderness 
on  pressure,  and  also  on  pressure  at  a  distance,  and  in  some  cases 
on  crepitus.  If  displacement  has  occurred,  the  displaced  frag- 
ment may  be  lifted  by  boring  into  it  with  a  coarse  gimlet  or  a 
slender  corkscrew.  Once  in  place  it  will  remain  so  without  assist- 
ance. The  front  of  the  chest  should  be  strapped  with  adhesive 
plaster  to  limit  motion. 

Fracture  of  the  Ribs. — Fracture  of  a  single  rib  is  an  extremely 
common  accident.  It  usually  is  the  result  of  a  fall  upon  a  sharp 
edge  or  corner.  The  ribs  most  exposed  are  oftenest  broken.  That 
is  to  say,  the  patient  falls  upon  his  side,  striking  upon  the  seventh, 
eighth,  ninth,  or  tenth  rib,  and  one  of  them  is  broken,  usually  in 
the  posterior  or  anterior  axillary  line.  Sometimes  the  rib  is  broken 
in  two  places  two  or  three  inches  apart.  There  is  usually  little 
or  no  displacement  of  the  broken  ends.  Pain,  after  the  first  feel- 
ing of  injury  has  passed  off,  is  not  great,  unless  the  patient  coughs, 
laughs,  or  sneezes.  The  pain  is  apt  to  increase  for  a  few  days, 
since  respiration  constantly  moves  one  broken  end  upon  the  other. 
To  avoid  this  the  patient  breathes  as  much  as  possible  with  his 
sound  side.  He  often  loses  some  sleep,  and  is  incapacitated  for 
hard,  work  for  three  or  four  weeks. 

The  symptoms  due  to  fracture  of  the  ribs  are  simulated  by 
those  which  follow  a  blow  from  some  sharp  object.  This  may  in- 
jure the  periosteum,  and  possibly  crack  the  bone,  although  definite 
signs  of  this  are  wanting.  There  is  tenderness  on  pressure,  and 
perhaps  pain,  although  the  pain  will  not  be  greatly  increased  by 
respiration  nor  by  pressure  upon  the  rib  at  a  distance  from  the 
point  of  injury,  as  is  the  case  in  complete  fracture.     There  is, 


KiS  INJURIES    AM)   INFLAMMATIONS   OF   THE  TRUNK 

after  a  few  days,  a  slight,  hard  swelling  close  to  the  bone  which 
simulates  a  callus,  bu1  is  of  less  extent,  and  the  deformity  is  less 
than  if  the  rib  were  fractured.  The  symptoms  usually  last  from 
one  to  three  weeks. 

Tbeatment. — The  pain  can  be  materially  lessened  by  apply- 
ing a  broad  strip  of  adhesive  plaster  directly  over  the  broken  rib. 
A  strip  five  or  six  inches  vide  and  long  enough  to  reach  half-way 
around  the  body,  should  be  fastened  posteriorly  first  and  then  be 
drawn  strongly  and  slowlv  forward  to  the  front  of  the  chest  and 
made  fast  by  pressing  it  close  to  the  skin.  The  more  tight  and 
smooth  the  fit  of  the  plaster,  the  greater  will  be  the  relief  to  the 
patient.  It  is  sometimes  recommended  that  when  one  end  of  the 
plaster  has  been  fastened,  the  patient  shall  expire  vigorously  while 
the  surgeon  quickly  draws  the  plaster  tight  and  sticks  it  to  the 
skin;  but  on  the  whole  a  more  satisfactory  result  can  be  obtained 
by  a  slower  and  more  careful  application  in  the  manner  described. 
It  is  better  that  the  plaster  should  cover  only  the  affected  side. 
This  leaves  the  well  side  free  to  expand  without  pulling  upon  the 
injured  side,  as  is  the  case  if  the  plaster  extends  all  the  way 
around  the  body.  If  the  skin  is  hairy  it  should  be  shaved  before 
the  plaster  is  put  on ;  otherwise  the  patient  will  hold  the  one  who 
removes  the  plaster  in  lasting  remembrance,  as  most  of  the  hairs 
will  be  so  firmly  embedded  in  the  gum  that  they  will  be  pulled 
out  by  the  roots  with  the  removal  of  the  plaster. 

Fractures  of  the  Vertebrae. — Owing  to  the  closeness  of  their 
articulations  to  one  another  and  to  the  ribs,  the  dorsal  vertebrae, 
except  the  lower  two  or  three,  are  rarely  fractured  by  indirect  vio- 
lence. Fracture  of  the  lower  dorsal  vertebras  and  of  the  lumbar 
vertebras  may  follow  a  severe  fall  or  blow  or  be  caused  by  a  bullet 
or  sharp  instrument.  In  most  cases  the  fracture  of  the  bone  is 
overshadowed  by  the  injury  to  the  cord.  As  this  does  not  extend 
below  the  first  lumbar  vertebra  the  prognosis  is  more  favorable 
the  lower  down  the  seat  of  fracture.  Life  may  be  prolonged  almost 
indefinitely  even  though  the  cord  be  seriously  injured,  but  sooner 
or  later,  in  spite  of  the  greatest  care,  the  patient  dies  from  sepsis 
due  to  the  extensive  ulcers  of  the  back  or  legs,  or  to  purulent 
cystitis,  or  to  pyelitis,  caused  by  the  unavoidable  catheterization. 

The  immediate  symptoms  of  fracture  of  a  vertebra  are  pain, 
tenderness,  edema,  and  at  least  partial  loss  of  motion  and  sensa- 


DISLOCATIONS  169 

tion.  Ecchymosis  is  usually  slow  in  making  its  appearance.  All 
of  these  symptoms  may  be  present  in  severe  cases  of  contusion 
without  fracture.  Signs  due  only  to  fracture  are  crepitus,  the  dis- 
placement of  a  spinous  process,  and  angular  deformity  produced 
when  the  spine  is  flexed  or  extended.  In  cases  in  which  there  is 
great  pressure  upon  the  cord  or  destruction  of  the  same,  there  will 
be  inability  to  urinate  or  defecate,  and  loss  of  sensation  and  motion. 

Treatment. — In  a  doubtful  case  of  fracture  the  patient 
should  remain  in  bed  until  tenderness  has  disappeared.  After  that 
the  treatment  given  on  page  158  is  applicable.  If  there  is  a  frac- 
ture without  injury  to  the  cord,  a  plaster  of  Paris  jacket  should 
be  applied  in  an  extended  position.  The  patient  may  be  allowed 
to  get  up  in  two  or  three  weeks,  but  should  wear  the  jacket  for 
two  months.  After  its  removal  he  should  be  treated  by  massage 
and  exercise,  with  plenty  of  rest  in  a  horizontal  position. 

The  treatment  of  fracture  accompanied  by  injury  to  the  cord 
is  beyond  the  scope  of  this  book. 

Dislocations. — Dislocation  of  Clavicle. — The  clavicle  may  be 
dislocated  from  the  sternum.  The  tendency  to  displacement  is  not 
marked,  and  a  pad  upon  the  overriding  bone,  with  light  pressure 
obtained  by  adhesive  plaster  strips  and  a  bandage,  will  usually 
prevent  its  recurrence.  If  this  is  not  successful,  a  periosteal 
suture  should  be  performed.  Fixation  by  either  method  should 
be  maintained  for  several  weeks. 

Dislocation  of  the  outer  end  of  the  clavicle  also  occurs.  The 
symptoms  are  usually  slight.  The  end  of  the  clavicle  projects  up- 
ward. It  is  easily  reduced  by  direct  pressure  or  by  drawing  the 
shoulder  outward.  This,  together  with  absence  of  crepitus  and 
the  absence  of  shortening  of  the  clavicle  when  measured  from  the 
sternum  to  the  outer  projecting  end,  will  differentiate  this  injury 
from  fracture ;  though  fracture  of  the  clavicle  sometimes  occurs 
without  shortening.  It  may  be  treated  in  the  same  manner  as  dis- 
location of  the  inner  end,  but  any  form  of  apparatus  usually  fails 
to  keep  the  end  of  the  clavicle  firmly  down  on  the  acromion.  This 
can  be  accomplished  by  passing  a  long  fine  drill  through  the  acro- 
mion and  well  into  the  clavicle,  and  leaving  it  in  place  for  eighteen 
days.     The  operation  should  be  carried  out  aseptically. 

Dislocation  of  Costal  Cartilage. — Sometimes  the  cartilage  of  the 
tenth  rib  may  be  separated  from  that  of  the  ninth  at  its  anterior 


170 


INJURIES   AM)    INFLAMMATIONS   OF   THE  TRUNK 


end,  and  by  its  occasional  slipping  forward  and  backward  give  rise 
to  a  little  pain.  The  radical  treatmenl  is  the  amputation  of  the 
anterior  tip  of  the  cartilage;  or  counter  irrjtants  may  be  applied 
until  the  acute  symptoms  subside  and  the  patient  grows  accustomed 
to  the  .sensation. 

Dislocation  of  Vertebra?. — Dislocation  of  either  dorsal  or  lum- 
bar vertebras  without  fracture  rarely  occurs,  and  when  it  does  so 
it  is  a  partial  dislocation  in  most  cases.  Attempts  at  reduction 
should  be  made  under  general  anesthesia  with  great  care  (see  p. 
125).     If  successful,  a  plaster  of  Paris  jacket  should  be  ap plied. 


ACUTE   INFLAMMATIONS 

Burns. — The  burns  which  occur  on  the  body  or  trunk  present 
no  especial  characteristics.  As  the  body  is  protected  by  the  cloth- 
ing, the  heat  applied,  whether  of  flame,  fluid,  or  vapor,  usually 

affects  a  consider- 
able area.  An  ex- 
ceptional case  is 
shown  in  Figure 
101.  This  man 
was  working  in  an 
iron  foundry,  with 
scanty  clothing, 
when  the  steam  in 
a  wet  mold  explod- 
ed and  spattered 
him  with  small 
drops  of  liquid 
iron. 

Treatment. — 
Directions  for  the 
treatment  of  burns 
have  been  given  on 
page  26.  The  im- 
mediate discomfort 
from  burns  of  the 
body  is  less  in  pro- 

Fig.    101. — Multiple    Burns   of   Body  of  Five  Days'  .  ,     . 

Duration  Produced  by  Spattering  Liquid  Iron.  portion      to      tlieir 


INSECT   BITES  171 

area  than  it  is  in  burns  of  the  head  and  neck,  and  on  this  account 
one  may  be  misled  into  making  an  nnduly  favorable  prognosis. 
When  the  destroyed  skin  begins  to  slough  the  gravity  of  the  situ- 
ation will  be  more  clear.  Hence  the  importance  of  saving  the 
strength  of  these  patients  in  every  way  from  the  very  first. 

Insect  Bites. — Pediculi. — By  the  marks  of  the  nails  one  can 
usually  make  a  diagnosis  of  pediculosis  corporis.  These  body  lice, 
which  are  vulgarly  called  "  graybacks,"  live  not  upon  the  person 
of  an  individual,  but  upon  his  clothing.  The  marks  of  their 
bites  are  insignificant.  The  itching  produced  is  extreme,  and  the 
patient  has  the  habit  of  drawing  his  nails  across  the  affected  part 
of  the  skin  in  long  sweeps.  Minute  excoriations  of  the  skin  often 
mark  the  track  of  these  long  scratches,  many  of  which  become 
infected,  so  that  shallow  ulcers  result,  which  heal  slowly,  often 
with  pigmentation.  The  diagnosis  of  the  trouble  can  generally 
be  made  from  the  appearance  of  the  skin.  A  search  in  the  under- 
clothing will  result  in  the  finding  of  pediculi.  Essential  treatment 
consists  in  the  destruction  of  the  parasites  by  baking  or  boiling 
the  clothing,  and  observance  of  personal  cleanliness.  The  itching 
often  persists  for  days,  so  that  an  antipruritic  may  be  indicated. 

Fleas  and  Bedbugs. — The  bites  of  fleas  and  bedbugs  can  usu- 
ally be  distinguished  by  their  distribution.  A  flea  travels  quickly 
from  one  place  to  another,  so  that  the  bites  of  a  single  insect,  from 
six  to  twelve  or  more  in  number,  will  often  be  scattered  over  half 
the  body.  A  bedbug,  on  the  other  hand,  makes  numerous  bites  in 
one  locality.  These  are  often  strung  out  in  a  row  like  the  splashes 
made  by  a  flat  stone  when  it  is  skipped  over  smooth  water.  It  is 
sometimes  difficult  to  distinguish  a  bite  from  the  lesions  of  urti- 
caria. If  the  latter  have  not  been  scratched,  the  skin  involved 
will  not  show  any  break;  whereas  the  skin  of  a  bite  made  by  a 
flea  or  a  bedbug  will  invariably  show  in  its  center  a  small  puncture. 

Treatment. — As  infection  is  often  caused  by  scratching  an 
insect  bite,  it  is  important  to  relieve  the  itching.  A  solution  of 
camphor  in  alcohol,  or  some  other  cooling  lotion,  is  good  for  this 
purpose.  Another  excellent  method  is  to  brush  the  involved  skin 
lightly  with  a  whisk-broom  or  a  not  too  stiff  hair-brush.  This 
relieves  the  itching  without  breaking  the  epidermis. 

Scabies. — Scabies  is  also  accompanied  by  itching,  so  that  the 
excoriations  may  obscure  the  burrows  of  the  insect.     A  minute 


172  INJURIES   AND    INFLAMMATIONS   OF  THE   TRUNK 

examination  of  the  skin  will  usually  reveal  the  characteristic  little 
row  of  brownish  specks  (the  fecal  masses  of  the  insect)  in  the 
substance  of  the  more  or  less  inflamed  skin.  If  the  lesions  are 
found  on  the  hands,  the  differentia]  diagnosis  from  pediculosis 
corporis  is  certain,  as  the  body  lice  do  not  bite  the  exposed  parts 
of  the  body. 

The  treatment  of  scabies  consists  in  the  disinfection  of  the 
clothing,  and  a  hot  bath  at  night,  followed  by  a  thorough  rub- 
bing of  all  suspected  portions  of  the  skin  with  sulfur  ointment. 
In  the  morning  another  bath  with  soap  and  water  should  be  taken. 
After  throe  »»r  four  days,  if  patches  of  the  disease  remain,  the  skin 
should  be  treated  again  in  the  same  manner. 

Herpes  Zoster. — This  disease,  on  account  of  its  predilection 
for  the  area  of  the  intercostal  nerves,  may  be  here  considered.  It 
develops  rather  suddenly  with  pain  and  some  fever,  followed 
by  an  eruption  of  groups  of  small  vesicles.  Often  the  skin 
supplied  by  a  single  nerve  is  affected;  sometimes  that  by  two 
adjacent  nerves;  rarely  that  supplied  by  two  opposite  nerves, 
making  it  bilateral.  It  runs  a  natural  course  to  termination 
with  drying  up  of  the  vesicles  in  a  few  days,  but  in  the  mean- 
time, by  the  burning  and  pain,  it  may  make  the  patient  very 
uncomfortable. 

Treatment. — The  vesicles  should  be  protected  from  rupture. 
The  burning  may  be  relieved  by  the  frequent  application  of  a 
solution  of  menthol  in  alcohol,  twenty  grains  to  the  ounce.  Mor- 
phin  may  be  required  to  control  the  pain  in  some  cases. 

Cellulitis  and  Dermatitis. — Cellulitis,  erysipelas,  and  the 
various  local  suppurative  processes  occur  frequently  upon  the 
trunk.  In  so  far  as  they  have  no  peculiar  characteristic  due 
to  their  situation,  the  description  of  them  and  the  treatment 
given  on  pages  33  et  seq.,  must  suffice.  Only  a  few  special 
forms  of  inflammation  will  be  described  in  this  section. 

Excoriation  of  the  Breast. — In  stout  women  the  constant  con- 
tact of  the  skin  of  a  pendulous  breast  with  that  of  the  abdomen 
may  lead  to  excoriation,  ulcer,  or  even  abscess.  These  conditions 
rapidly  disappear  under  suitable  treatment.  As  a  preventive  the 
parts  should  be  bathed  frequently,  the  skin  rubbed  with  alcohol, 
and  dusted  with  a  talcum  powder.  If  an  ulcer  has  formed,  wet 
dressings  should  be  employed. 


MAMMARY    ABSCESS  173 

Mammary  Abscess. — The  common  period  for  the  occur- 
rence of  an  abscess  of  the  breast  is  during  early  lactation,  and 
especially  the  first  lactation.  The  infection  takes  place  through 
a  crack  or  excoriation  of  a  too  tender  nipple,  and  this  can  almost 
always  he  found  upon  search.  The  usual  signs  of  suppuration 
are  present.  A  portion  of  the  mammary  gland  and  the  overlying 
skin  are  indurated  and  tender,  and  in  the  center  of  this  affected 
area  there  can  usually  be  made  out  a  smaller  area  of  fluctuation. 

Treatment. — If  the  inflammation  is  seen  at  an  early  stage, 
wet  applications  should  be  made  to  the  nipple  and  breast,  either 
cold  compresses,  or  flaxseed  poultices,  or  wet  compresses  with  heat 
applied  externally,  as  spoken  of  in  connection  with  abscess  of  the 
head  (p.  38).  A  baby  should  not  be  put  to  the  inflamed  breast, 
although  he  may  continue  to  nurse  from  the  opposite  one  if  the 
mother  has  only  a  slight  degree  of  fever.  The  milk  should  be 
drawn  regularly  from  the  affected  breast,  and  if  in  a  day  or  two  it 
is  seen  that  the  inflammatory  process  is  increasing,  an  incision 
should  be  made  into  the  center  of  the  indurated  area,  where,  as 
above  stated,  a  soft  spot  can  usually  be  felt.  If  the  softened  area 
is  plainly  palpable,  it  is  useless  to  further  postpone  operation. 
The  incision  may  be  made  under  local  or  general  anesthesia.  It 
should  invariably  be  made  in  a  line  radiating  from  the  nipple. 
Neglect  to  observe  this  rule  has  led  to  the  division  of  milk  ducts 
and  the  establishment  of  a  mammary  fistula. 

An  abscess  of  the  breast  has  a  strong  tendency  toward  recovery, 
and  the  incision  therefore  does  not  need  to  be  much  longer  than 
the  diameter  of  the  suppurating  area.  The  cavity  should  be  thor- 
oughly washed  out  with  a  solution  of  bichlorid  of  mercury, 
1 :  2,000,  and  a  dilute  solution  of  peroxid  of  hydrogen,  one  part 
to  five.  A  drain  should  be  inserted  in  the  abscess-cavity,  but  it 
should  not  greatly  distend  it.  The  hot,  moist,  gauze  dressing 
should  be  continued.  Under  these  circumstances  any  further  se- 
cretion of  pus  quickly  finds  its  way  into  the  dressing,  and  the 
wound  has  an  opportunity  to  heal  just  as  rapidly  as  it  is  able  to 
do  so.  Not  until  the  repair  has  reached  the  subcutaneous  fatty 
tissue  should  the  drain  be  omitted. 

Often  in  an  abscess  of  the  breast  which  has  lasted  for  some 
time,  so  that  the  zone  of  cellulitis  about  the  pus  cavity  is  not  an 
excessive   one,   incision  and  cleansing  will  terminate  the  whole 


174  LNJUKIES    AND    [NFLAMMATIONS   OF   THE   TRUNK 

pathological  process  so  that  the  sides  of  the  cavity  will  adhere 
and  almosl  primary  union  of  the  wound  will  follow.     If  this  rapid 

method  of  cuiv  be  attempted,  tin-  dressing  should  be  changed  at 
least  every  day,  and  if  there  is  any  retained  discharge,  the  cavity 
should  be  washed  out  again  and  the  drain  inserted  to  a  greater 
depth. 

If  the  suppuration  is  more  excessive  and  has  passed  beyond 
the  capsule  of  the  gland  and  has  lifted  up,  as  is  frequently  the 
case,  a  portion  of  the  gland  from  the  underlying  ribs,  more  than 
one  incision  may  be  necessary  to  provide  suitable  drainage.  Under 
such  circumstances,  one  incision  should  be  made  at  the  most  de- 
pendent portion  of  the  abscess-cavity  as  the  patient  lies  in  bed  or 
as  she  sits  up,  according  to  circumstances.  If  she  is  up  most  of 
the  time,  the  most  favorable  point  for  drainage  is  immediately 
below  the  breast,  whereas  if  she  is  lying  in  bed  the  outer  edge 
of  the  breast  or  a  point  between  this  and  the  lower  edge  will  be 
found  most  serviceable.  If  the  jms  shows  a  tendency  to  approach 
the  surface  at  any  point,  that  place  should  he  selected  for  one  of  the 
incisions,  as  there  are  other  factors  connected  with  perfect  drain- 
age besides  the  force  of  gravity,  and  unless  there  are  plain  contra- 
indications the  point  chosen  by  nature  for  the  discharge  of  pus 
had  best  be  accepted  by  the  surgeon  as  the  most  suitable  one. 

The  best  drain  for  these  cases  is  made  by  cutting  the  tip  from 
a  rubber  finger  cot  and  passing  through  it  a  wick  of  gauze.  In 
this  manner  the  gauze  will  be  prevented  from  sticking  to  the  sides 
of  the  wound.  The  rubber  is  more  flexible  and  stronger  than  the 
gutta  percha  tissue  usually  employed  in  a  "  cigarette  "  drain. 

Preventive  Treatment. — The  physician  who  has  charge  of 
a  pregnant  woman  should  give  her  directions  for  the  enlargement 
and  toughening  of  the  nipples  by  daily  massage,  applications  of 
alcohol,  alum,  etc.,  and  if  they  are  retracted  they  should  be  drawn 
out  with  a  breast-pump.  In  this  manner  they  can  be  prepared  for 
nursing  two  or  three  months  before  the  birth  of  the  child,  and 
cracked  nipples  and  mammary  abscesses  can  almost  invariably  be 
avoided. 

Axillary  adenitis  and  suppuration  are  described  in  Chap- 
ter XV. 

Inguinal  adenitis  and  suppuration  are  described  in  Chap- 
ter VIII. 


EMPYEMA  175 

Umbilical  Suppuration. — The  skin  of  the  umbilicus  may 
ulcerate  or  an  abscess  may  form  as  a  result  of  the  irritation  which 
is  produced  in  a  deep  umbilicus  by  the  dirt  and  scent  inns  which 
may  collect  there,  and  even  form  a  hard  ball.  Cleanliness  and 
moist  antiseptic  dressings  will  speedily  effect  a  cure.  Umbilical 
sinus,  which  may  also  suppurate,  is  described  on  page  181. 

Bed-sores. — An  ulcer  of  the  skin  of  a  bedridden  patient 
caused  by  pressure  upon  some  one  point  is  called  a  bed-sore. 
The  sacral  region  is  the  commonest  situation,  both  on  account 
of  its  p°or  blood-supply  and  the  habit  many  patients  have  of 
lying  the  whole  time  upon  their  back.  There  is  first  a  dusky 
redness  over  the  area  about  the  size  of  a  quarter  of  a  dollar,  then 
the  epithelium  gives  way  at  the  center  and  a  sore  is  started  which 
gradually  involves  the  whole  thickness  of  the  skin,  or  possibly  the 
whole  thickness  of  the  skin  is  at  once  involved  and  becomes  dark 
and  gangrenous  and  sloughs  leaving  a  large  ulcer.  The  skin  over 
the  great  trochanter  is  also  often  the  seat  of  a  bed-sore.  The  rapid- 
ity with  which  a  bed-sore  may  form,  especially  in  a  patient  weak- 
ened by  long  disease,  is  truly  amazing. 

Treatment. — Frequent  massage  and  the  use  of  alcohol  will 
usually  prevent  the  formation  of  an  ulcer  if  the  weight  of  the 
body  is  supported  upon  soft  pillows  or  an  air-ring,  so  that  the 
pressure  upon  the  bony  prominences  is  avoided.  When  an  ulcer 
has  formed,  it  should  be  washed  frequently  with  mild  antiseptics 
and  dressed  with  a  mildly  stimulatingjpreparation.  Compare  the 
treatment  of  ulcers  of  the  leg,  given  in  Chapter  XVIII. 

Empyema. — Pus  in  the  pleural  cavity,  or  empyema,  is  a  con- 
dition demanding  surgical  treatment.  The  signs  of  empyema  are 
fever,  increased  pulse  and  respiration,  dulness  or  flatness  in  the 
lower  portion  of  the  affected  side  of  the  chest,  above  which  is 
usually  a  zone  of  bronchophony  with  pleuritic  rales.  The  diag- 
nosis is  not  always  an  easy  one  to  make,  and  the  importance  of 
prompt  drainage  is  great,  so  that  in  a  doubtful  case  it  is  better  to 
make  one  or  more  exploratory  punctures  in  order  to  be  certain  of 
the  presence  and  the  location  of  the  pus.  These  punctures  should 
be  made  with  a  large  hypodermic  needle.  The  needle  used  by 
veterinary  surgeons  for  hypodermic  injection  is  just  right  for  the 
purpose.  The  syringe  need  not  be  a  large  one ;  an  ordinary  hypo- 
dermic syringe  is  large  enough. 


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SYPHILIS  177 

Treatment. — When  pus  has  been  shown  to  he  present  in  the 
pleural  cavity,  drainage  should  be  accomplished  by  the  removal 
of  an  inch  and  a  half  of  the  eighth  or  ninth  rib  in  the  posterior 
axillary  line.  The  operation  may  be  performed  under  a  general 
anesthetic,  but  if  the  restoration  is  embarrassed  by  the  amount  of 
fluid  in  the  pleura,  a  local  anesthetic  is  safer.  The  instruments 
required  are  shown  in  Figure  102.  The  soft  parts  overlying  the 
rib  are  cut  through  parallel  to  its  long  axis  for  a  distance  of  two 
or  three  inches,  the  scalpel  being  pressed  firmly  against  the  rib 
so  as  to  split  its  periosteum.  This  is  then  reflected  above  and 
below,  and  bone  shears  passed  between  the  inner  portion  of  peri- 
osteum and,  the  rib.  An  inch  of  the  rib  is  removed  and  its  cut 
edges  trimmed  if  rough.  The  pleural  cavity  is  then  opened  in 
the  long  axis  of  the  rib,  and  when  most  of  the  pus  has  escaped  two 
soft-rubber  tubes  pierced  by  the  same  safety  pin  are  inserted.  A 
stitch  at  either  end  of  the  wound  is  an  advantage.  A  dry  creolin 
gauze  dressing  is  applied  and  changed  as  often  as  it  becomes  mois- 
tened by  pus.  Forced  expiration  should  be  practised  as  soon  as  the 
soreness  of  the  wound  has  somewhat  subsided,  say  by  the  fifth 
day.  The  patient  is  shown  how  to  blow  colored  water  from  one 
Wolff  bottle  to  another.  This  exercise  should  be  kept  up  for  five 
minutes,  and  repeated  several  times  a  day.  It  is  of  the  greatest 
service  in  stretching  the  collapsed  lung  so  as  to  make  it  resume  its 
normal  space  in  the  pleural  cavity.  The  force  of  expiration  can 
be  increased  by  elevating  the  second  bottle  a  few  inches. 

Drainage  with  two  tubes  should  be  continued  until  granula- 
tions have  shut  off  the  pleural  cavity  from  the  wound.  The  tubes 
may  be  shortened  a  half  inch  at  a  time  as  the  cavity  grows  smaller, 
but  they  should  not  be  removed  as  long  as  they  enter  the  pleural 
cavity;  nor  should  they  be  replaced  by  tubes  of  smaller  caliber. 
Neglect  of  this  rule  has  turned  acute  cases  into  chronic  ones  and 
made  secondary  operations  necessary  to  reestablish  drainage. 

CHRONIC   INFLAMMATIONS 

Syphilis. — The  trunk  has  its  full  share  of  the  secondary  and 
tertiary  lesions  of  syphilis.  An  isolated  gumma,  appearing  long 
after  all  other  manifestations  of  the  disease  have  disappeared,  is 
often  a  puzzle  in  diagnosis.     A  common  seat  for  the  same  is  the 


178  INJURIES    AND    INFLAMMATIONS   OF   THF   TRUNK 

region  of  the  sternum.  The  constitutional  treatment  is  important. 
Any  protective  dressing  will  answer  locally. 

Tuberculosis. — Tuberculosis  involves  the  skin  of  the  trunk, 
and  especially  of  the  back  (lupus).  Its  essential  characteristics 
arc  the  same  as  those  of  the  disease  when  seated  in  the  skin  of 
the  face  (see  p.  63).  Because  of  the  concealed  situation,  more 
radical  excision  and  skin-grafting  are  permissible. 

Tuberculosis  of  the  bones  and  joints  of  the  trunk  is  so  fully  dis- 
cussed in  larger  works  upon  surgery  and  orthopedic  surgery  that  it 
will  be  considered  here  chiefly  for  the  sake  of  early  diagnosis. 

Tuberculosis  of  the  Sternoclavicular  Articulation. — This  joint 
is  attacked  by  tuberculosis  as  well  as  by  syphilis.  In  either  case 
the  periarticular  tissues  are  swollen.  In  tuberculosis,  one  or  more 
tender  spots  in  the  end  of  the  clavicle  can  usually  be  made  out. 
Later  an  abscess  may  form  and  rupture. 

If  treatment  by  fixation  is  determined  upon,  it  is  easily  secured 
by  keeping  the  arm  bandaged  to  the  chest  and  carrying  the  fore- 
arm in  a  sling. 

Costal  Tuberculosis. — One  or  more  ribs  may  be  attacked  by 
tuberculosis.  The  general  health  of  the  patient  suffers  little,  so 
that  the  disease  may  be  disregarded  for  some  time.  When  the 
patient  first  comes  for  examination,  there  may  be  an  abscess  or  a 
sinus,  the  pus  having  already  broken  through  the  skin.  A  probe 
will  follow  such  a  sinus  obliquely  to  the  eroded  bone.  The  fingers 
will  recognize  that  beyond  the  abscess-cavity  the  periosteum  is 
thickened.  More  than  one  rib  is  often  involved,  the  extent  of  the 
disease  being  greater  in  one  than  in  the  other.  Erosion  of  the 
inner  surface  of  the  rib  is  usually  more  extensive  than  that  of  its 
outer  surface. 

Operative  treatment  is  strictly  indicated,  and  should  be  car- 
ried out  under  general  anesthesia.  An  incision  should  be  made 
over  the  affected  rib  parallel  to  its  long  axis,  and  the  diseased  bone, 
periosteum,  and  other  tissues  fully  removed.  This  can  usually 
be  accomplished  without  opening  the  pleural  cavity,  so  that  the 
shock  of  operation  is  slight.  The  wound  should  be  fully  drained. 
Recovery  from  the  operation  is  prompt,  but  the  patient  should  be 
kept  under  observation  for  a  considerable  time,  as  extension  of 
the  process  along  the  same  or  adjacent  ribs  is  the  rule  rather  than 
the  exception. 


TUBERCULOSIS  179 

Tuberculosis  of  the  Vertebrae. — The  symptoms  of  tuberculosis 
of  the  cervical  vertebrae  have  been  given  on  page  133.  When  the 
disease  is  situated  in  the  dorsal  or  lumbar  vertebrae,  the  symp- 
toms elicited  vary  somewhat  according  to  the  accessibility  of  the 
parts  to  palpation,  and  the  varying  degrees  of  motion  that  are 
their  normal  possession.  An  essential  to  diagnosis  in  every  case 
is  a  thorough  examination  of  the  whole  back,  stripped  to  the  skin 
for  the  purpose.  Such  an  examination  will  almost  always  enable 
the  surgeon  to  state  positively,  even  in  the  early  stages  of  the  dis- 
ease, not  only  that  the  spine  is  affected,  but  that  the  disease  is  situ- 
ated in  certain  vertebrae.  The  various  symptoms  to  be  observed 
are:  Slight  edema  along  the  spinous  processes,  slight  deformity 
(which  often  disappears  entirely  in  some  positions),  tenderness 
when  the  affected  vertebrae  are  pressed  upon  (a  sign  often  absent 
in  children  who  cannot  or  will  not  differentiate  pressure  upon  one 
vertebra  from  that  on  another),  and  rigidity  or  a  lack  of  freedom 
in  using  the  affected  part  of  the  spine.  Compare  the  tests  for 
sprain  of  the  back  given  on  page  162.  A  symptom  which  is 
chronologically  a  late  one,  but  which  is  sometimes  the  first  thing 
a  patient  notices,  is  the  swelling  due  to  an  abscess.  This  may  be 
situated  near  the  spine  posteriorly  or  it  may  come  to  the  surface 
at  the  side  of  the  trunk,  or  following  down  the  front  of  the  spine  it 
may  appear  above  or  below  Poupart's  ligament. 

Treatment. — As  is  well  known,  the  treatment  for  a  tubercu- 
lous focus  which  cannot  be  removed  is  immobilization,  and  relief 
from  pressure.  In  the  case  of  the  spine  these  objects  are  partially 
obtained  by  a  plaster  jacket  or  a  brace,  and  more  perfectly  ob- 
tained by  a  stretcher  frame,  a  form  of  apparatus  especially  adapted 
to  a  child  of  four  years  or  less. 

Sacroiliac  Tuberculosis. — Another  common  seat  for  tuberculosis 
is  the  sacroiliac  synchondrosis.  The  difficulty  of  recognizing  the 
disease  in  this  situation  is  great,  so  that  a  correct  diagnosis  is  often 
not  made  for  a  long  time.  A  history  of  traumatism  is  apt  to 
be  confusing;  the  traumatism  may  have  caused  the  trouble  or  be 
entirely  independent  of  it.  In  either  case  it  is  apt  to  mislead  the 
surgeon  into  thinking  that  he  has  to  do  with  a  severe  sprain.  The 
early  symptoms  are  pain,  slight  fever,  and  a  disinclination  to 
exertion.  As  there  is  practically  no  motion  between  the  ilium 
and  sacrum,  the  best  sign  of  tubercular  joint  disease,  namely,  limi- 
14 


180         INJURIES    AND  INFLAMMATIONS  OF  THE  TRUNK 

tation  of  motion,  is  in  this  case  wanting;  ye1  the  patient  moves 
with  awkwardness  and  unusual  care  when  he  is  asked  to  stoop,  rise, 
sit,  squat,  etc.  If  there  is  no  history  of  injury  the  diagnosis  of 
rheumatism  is  apt  to  be  made.  The  age  of  the  patient,  the  limi- 
tation.of  the  trouble  to  a  joint  to  which  rheumatism  is  rarely  if 

ever  confined,  and  the  slighl   bu1  constanl   aftern i   fever,  serve 

to  differentiate  the  two  diseases. 

Treatment.- — In  tuherculosis,  of  course,  no  benefit  Eollows  the 
administration  of  salicylates.  Treatment  is  eminently  unsatis- 
factory. Cases  have  been  recorded  in  which  an  early  resection  of 
the  joint  has  led  to  recovery,  but  owing  to  the  fad  that  a  diagnosis 
i-  usually  not  made  until  pus  appears  either  in  the  groin  or  in 
the  buttock,  the  most  favorable  period  for  radical  treatment  has 
already  passed,  so  that  operations  are  usually  palliative,  to  afford 
a  more  direct  exit  for  the  pus  and  so  to  relieve  the  patient  of  pain 
and  some  fever.  Tl>e  usual  course  is  a  steady  decline  through  some 
years  to  death,  unless  the  resisting  power  of  the  patient  can  be 
raised  by  hygienic  measures. 

Tuberculosis  of  the  Mammary  Gland. — One  of  the  less  common 
situations  for  tuberculosis  is  the  mammary  gland.  Because  of  its 
rarity,  and  because  of  the  similarity  of  the  lesion  in  its  general 
outline  to  carcinoma  of  the  breast,  this  mistaken  diagnosis  is  often 
made.  There  will  generally  be  a  history  of  tuberculosis  in  the 
patient,  or  examination  of  the  corresponding  lung  may  show  that 
the  primary  trouble  was  located  within  the  chest  and  has  worked 
outward.  If  an  ulcer  or  sinus  exists  its  appearance  will  keep  an 
observant  man  from  making  a  wrong  diagnosis.  There  will  be  in 
the  edges  of  the  tubercular  ulcer  none  of  the  active  growth  which 
is  always  seen  in  the  edges  of  a  carcinomatous  ulcer.  The  axil- 
lary glands  are  usually  enlarged  if  an  ulcer  exists. 

Treatment.- — In  tuberculosis  of  the  breast  it  is  quite  unneces- 
sary to  remove  more  than  the  affected  part.  Usually  the  whole 
gland  is  diseased  at  the  time  of  operation,  but  unless  the  axillary 
glands  are  plainly  diseased  it  is  wrong  to  subject  the  patient  to 
the  extra  shock  of  an  axillary  dissection.  On  account  of  the  pos- 
sible involvement  of  an  underlying  rib,  a  general  anesthetic  is 
preferable.  If  the  disease  is  plainly  limited  to  the  freely  movable 
breast-gland,  a  complete  removal  can  be  satisfactorily  effected 
under  local  anesthesia  if  the  patient's  temperament  warrants  it. 


CIIAPTEE    VTT 

TUMORS    AND    DEFORMITIES    OF    THE    TRUNK 

TUMORS 
CYSTIC    TUMORS    OF    THE    TRUNK 

Sebaceous  Cysts. — These  cysts  occur  less  often  upon  the 
trunk  than  upon  the  head.  They  are  very  rare  below  the  waist 
line.  They  have  the  same  characteristics  as  those  of  the  head 
(p.  66)   and  require  the  same  treatment. 

Umbilical  Cysts  and  Sinuses. — It  sometimes  happens  that 
the  duct  which  in  fetal  life  leads  from  the  umbilicus  to  the  blad- 
der, and  which  is  called  the  urachus,  is  not  completely  closed  at 
birth.  Or  it  may  be  closed  in  part.  As  a  result  there  may  be  a 
sinus  discharging  urine,  or  a  short  sinus  with  a  slight  discharge 
of  sebaceous  material,  or  a  cyst  lined  with  epithelium  and  contain- 
ing sebaceous  material.  Or  it  may  have  no  external  orifice  and 
may  first  manifest  itself  as  a  tumor  situated  below  the  umbilicus 
and  containing  sebaceous  material. 

Treatment. — The  cyst  or  sinus  should  be  removed  by  dissec- 
tion through  an  elliptical  incision  made  close  around  it.  In  some 
cases  this  is  very  easy;  in  others  it  is  necessary  to  open  the  peri- 
toneum for  a  short  distance.  As  it  is  impossible  to  know  this 
beforehand,  the  operation  should  be  performed  with  extreme  asep- 
tic precautions.  When  the  cyst  or  sinus  has  been  removed,  the 
abdominal  wall  should  be  closed  in  three  layers — peritoneum,  deep 
fascia,  and  skin — in  order  to  prevent  hernia.  As  the  condition  is 
an  annoying  one,  rather  than  one  which  interferes  with  healthy 
development,  the  operation  may  be  safely  postponed  if  the  patient 
is  an  infant,  until  it  is  some  years  old. 

Coccygeal    Cysts    and    Sinuses. — These  formations  are 

congenital  in  origin,  but  they  may  not  be  noticeable  until  adult 

life.      In  their  simplest  form  the  skin  at  the  lower  end  of  the 

181 


]S2  TUMORS   AND   DEFORMITIES   OF  THE  TRUNK 

spine  is  so  folded  in  upon  itself  that  it  forms  an  isolated  cyst, 
lined  with  epithelium,  or  a  sinus  also  lined  with  epithelium,  one 
or  both  ends  of  which  reach  the  surface  of  the  skin.  As  the  epi- 
thelium contains  hair-roots,  such  a  cyst  or  sinus  is  likely  to  fill  up 
with  sebaceous  material  and  short  hairs.  If  near  the  surface  the 
contents  may  discharge  from  time  to  time.  Such  a  cyst  or  sinus 
is  usually  situated  low  down  in  the  median  line  over  the  coccyx 
or  sacrum.  It  is  likely  to  become  inflamed  from  time  to  time. 
With  the  discharge  of  a  mixture  of  sebaceous  material  and  pus, 
the  acute  signs  of  inflammation  subside. 

Treatment. — To  rid  the  patient  of  this  annoying  condition 
the  cyst  or  sinus  should  be  fully  exposed  by  a  median  incision  and 
all  traces  of  an  epithelial  structure  removed.  The  wound  may 
then  he  closed  by  suture,  and  primary  union  be  anticipated  even 
if  acute  infection  is  present;  although,  if  the  infection  is  marked, 
it  is  advisable  to  drain  with  a  wick  of  rubber  tissue  some  portion 
of  the  wound.  At  the  change  of  dressing  on  the  first  or  second 
day  this  should  be  removed,  and  if  the  inflammation  has  subsided 
it  should  not  be  reinserted.  The  operation  is  readily  performed 
under  local  anesthesia. 

Dermoid  Cysts. — There  are  other  dermoid  tumors  in  the 
region  of  the  coccyx  which  may  contain,  in  addition  to  sebaceous 
material  and  hair,  fragments  of  bone  and  other  structures,  or  even 
fairly  well  developed  portions  of  another  fetus  or  twin.  They 
should  be  removed  and  the  gap  closed  by  a  plastic  operation  or 
by  skin  grafts. 

CYSTIC    TUMORS    OF    THE    BREAST 

Retention  Cysts  of  Infancy. — An  infant's  breast  some- 
times secretes  a  milky  fluid,  which  collects  in  the  larger  ducts 
about  the  nipple,  and  forms  a  soft  fluctuating  swelling.  If  the 
secretion  is  forcibly  expressed  from  the  nipple  once  or  twice  the 
swelling  will  disappear. 

Retention  cyst  in  the  adult  may  be  due  to  scar  tissue,  fol- 
lowing abscess  of  the  breast,  or  perhaps  a  misdirected  incision. 
It  will  usually  not  be  necessary  to  excise  such  a  cyst.  If  it 
is  split  open  and  drained  the  normal  granulations  will  obliter- 
ate its  cavity.  (Compare  the  description  of  a  salivary  cyst  on 
page  71.) 


GRANULOMA   OF   THE    UMBILICUS  183 

Simple    Cysts    and   Cystic   Adenomata. — Cysts   of   the 

mammary  gland  apparently  due  to  disordered  gecretion  are  very 
common  in  young  women.  Such  a  tumor  is  freely  movable, 
rounded,  and  clastic;  but  it  is  very  difficult  to  obtain  fluctuation 
in  it  on  account  of  its  small  size.  It  cannot  always  be  differ- 
entiated from  a  solid  tumor,,  except  by  aspiration.  Moreover, 
the  withdrawal  of  fluid  does  not  absolutely  distinguish  the  two, 
as  many  adenomata  and  some  malignant  tumors  contain  cysts. 
Naturally,  in  such  a  case,  the  withdrawal  of  the  fluid  will  not  so 
collapse  the  tumor  as  it  will  a  simple  cyst.  The  fluid  may  be  like 
serum,  straw-colored,  or  it  may  have  a  pink,  red,  or  brown  tint. 

Treatment. — Aspiration  as  a  means  of  diagnosis  has  been 
spoken  of.  It  sometimes  cures  the  patient,  the  fluid  not  again 
accumulating.  Should  this  happy  result  not  follow,  or  should  the 
withdrawal  of  fluid  not  cause  the  immediate  collapse  of  the  tumor, 
operation  is  indicated.  Small  tumors  can  be  removed  from  the 
breast  under  cocain;  but  on  account  of  the  sensitiveness  of  the 
part,  and  of  the  patient,  a  general  anesthetic  is  better  in  most 
cases.  If  the  operation  is  a  short  one  the  patient  can  rise  and  go 
home  in  a  few  minutes.  It  is  well  to  bear  in  mind  that  a  small, 
easily  movable  tumor  seems  much  nearer  the  surface  during  pal- 
pation than  it  does  when  one  is  cutting  through  skin,  fat,  and 
fascia  and  an  outer  layer  of  the  mammary  gland  in  the  search  for 
it.  It  is  a  help  to  have  the  assistant  seize  the  gland  on  either  side 
and  stretch  the  skin  tightly  over  the  tumor  while  the  incision  is 
being  made. 

The  incision  itself  should  radiate  from  the  nipple.  So  much 
of  the  mammary  gland  as  contains  the  cyst  should  be  removed  by 
an  elliptical  or  a  pie-shaped  incision.  The  wound  in  the  gland 
should  be  closed  by  catgut  sutures,  and  the  wound  in  the  skin 
should  be  closed  by  silk  sutures.  No  drainage  should  be  used,  or 
at  most  a  small  wick  of  gutta  percha  tissue  introduced  through 
the  skin  to  provide  for  the  escape  of  blood. 

SOLID    BENIGN   TUMORS   OF  THE   TRUNK 

Granuloma  of  the  Umbilicus. — Excessive  granulation 
sometimes  follows  the  removal  of  the  stump  of  the  umbilical  cord. 
Owing  to  the  confined  situation  the  mass  of  granulations  gradu- 
ally assumes  a  polypoid  shape. 


l.sl  TUMORS    AM j   DEFORMITIES   OF  THE  TRUNK 

Treatment. — This  condition  is  easily  cured  by  the  applica- 
tion of  a  drop  of  pure  carbolic  acid  <>n  a  wooden  toothpick.  A 
.slower  hut  safer  and  no  less  certain  method  is  the  daily  applica- 
tion of  undiluted  hydrogen  peroxid  upon  a  minute  cotton  swab. 
This  method  is  preferable  if  the  point  from  which  the  granula- 
tions spring  is  so  hidden  by  folds  of  fat  that  it  is  not  readily 
brought  into  view. 

Intra-abdominal  Complications. — In  rare  cases  a  poly- 
poid tumor  of  the  umbilicus  is  covered  with  mucous  membrane; 
or  it  may  be  lined  with  mucous  membrane  and  communicate 
with  the  intestine.  It  should  be  removed,  but  not  until  one 
has  at  hand  sutures  to  close  a  possible  opening  into  the  in- 
testine, and  others  to  close  a  gap  in  the  abdominal  wall  if 
necessary. 

Keloid. — -This  firm,  smooth  tumor  occurs  in  scars,  especially 
in  those  of  the  trunk.  It  is  made  up  of  fibrous  tissue,  is  inti- 
mately connected  with  the  corium,  projects  a  quarter  of  an  inch 
more  or  less  above  the  level  of  the  skin,  and  is  covered  with  a 
shiny  epithelium  of  poor  quality,  in  which  dilated  vessels  are 
often  seen.  At  an  early  stage  of  its  development  it  cannot  be 
told  from  a  hypertropbied  scar.  As  time  goes  on,  however,  the 
hypertrophied  scar  tends  to  shrink  and  lose  its  pink  color,  while 
the  keloid  maintains  its  size  or  continues  to  grow,  exceeding  the 
original  limits  of  the  scar,  and  sometimes  sending  out  prolonga- 
tions into  the  skin  around,  which  have  been  compared  to  crabs' 
claws,  hence  the  name  keloid.  When  a  keloid  develops  in  a  wound 
which  has  been  sutured,  the  scars  of  the  individual  stitches  some- 
times give  rise  to  a  greater  growth  than  the  line  of  incision  itself. 
The  skin  of  the  negro  is  peculiarly  susceptible  to  the  formation 
of  keloids. 

Treatment. — Surgical  ingenuity  has  not  yet  succeeded  in 
evolving  a  generally  successful  cure  of  keloid.  Individual  cures 
by  various  means  have  been  reported,  by  dissection,  by  caustics, 
by  long-continued  elastic  pressure,  and  by  the  X-ray.  If  the  orig- 
inal scar  was  a  bad  one,  and  the  surplus  skin  in  the  vicinity  per- 
mits of  a  complete  dissection,  with  suture  of  the  wound  and  prob- 
able primary  union,  this  plan  is  worth  trying.  The  suture  should 
be  an  intracuticular  one,  or  the  interrupted  stitches  of  fine  silk 
should  be  removed  at  the  earliest  possible  moment,  about  four 


LIPOMA 


185 


days.  Tension  upon  the  new  scar  should  be  prevented  by  cross 
strips  of  adhesive  plaster  for  several  weeks.  But  even  when  all 
these  precautions  are  taken  recurrence  often  follows. 

Papilloma :  Fibroma  :  Fibrolipoma. — These  names  are 
given  to  pedunculated  tumors  of  fat  and  fibrous  tissue  covered 
with  essentially  normal  skin.  They  vary  in  size  from  that  of  a 
pin-head  to  one  inch  or  more  in  diameter.  Frequently  the  tumors 
are  multiple.     The  pedicle  is  usually  small,  but  always  contains 


Fig.  103. — Fibrolipomata   of  the   Back,  of  Five  Years'  Duration.     Patient  a 
girl  aged  nineteen  years. 

an  artery  of  a  size  corresponding  to  the  size  of  the  tumor.  In  this 
respect  they  differ  from  lipoma  in  which  the  blood-supply  is  very 
scanty  (Fig.  103).  A  papilloma  is  a  strictly  benign  growth,  but 
on  account  of  the  annoyance  caused  by  it,  and  its  tendency  to  in- 
crease in  size,  it  had  best  be  removed. 

Treatment. — A  small  papilloma  may  be  snipped  off  even  with 
the  surface  of  the  skin  with,  a  pair  of  scissors.  A  larger  one  should 
be  removed  by  an  elliptical  incision  close  to  the  base  of  the  pedicle, 
made  through  the  whole  thickness  of  the  skin.  Such  a  wound 
when  sutured  will  give  the  minimum  of  deformity. 

Lipoma. — Lipoma  of  the  trunk  is  relatively  common,  espe- 
cially upon  the  shoulders.  Such  a  tumor  is  lobulated,  and  while 
growing  in  the  layer  of  subcutaneous  fat  its  septa  are  intimately 
adherent  to  the  skin.  Hence  the  skin  is  dimpled  when  an  attempt 
is  made  to  lift  it  from  the  tumor.     This  is  one  of  the  diagnostic 


186 


TUMOKS    AM)    DEFORMITIES    UK   THE   TKUNK 


signs  of  Lipoma  of  the  simple  subcutaneous  t \  | >< -.  It  is  well  en- 
capsulate! liv  thin  plant's  of  connective  tissue,  so  that  it  is  easily 
shelled  out. 

Treatment. — On  account  of  the  insensitiveness  of  the  parts 
involved  below  the  skin  the  removal  of  even  a  large  lipoma  of  the 
trunk  can  readily  be  accomplished  with  a  local  anesthetic  (Figs. 
104  and  105).  This  applies  only  to  the  simple  or  usual  type  of 
lipoma.  For  a  description  of  the  diffuse  lipoma  and  of  the  inter- 
muscular lipoma,  both  of  which  varieties  are  found  in  the  trunk, 


Fig.  104. — Lipoma  of  Back.  Two  years'  duration;  removed  without  pain,  with  an 
injection  of  40  minims  of  2  per  cent,  cocain  solution.  Another  view  of  tumor  is 
shown  in  the  upper  corner. 


see  page  139.  The  skin  is  incised  for  a  distance  equal  to  one-half 
or  more  of  the  diameter  of  the  tumor.  If  the  tumor  is  covered 
by  a  layer  of  the  subcutaneous  fat,  this  is  also  divided  so  that 
the  capsule  of  the  tumor  shall  be  exposed.     This  capsule  is  next 


ADENOMA 


1X7 


divided,  and  then  the 
fatty  tumor  can  be 
readily  peeled  out  of 
its  compartments  in 
the  fascia,  by  a  blunt 
and  generally  blood- 
less dissection,  with 
the  fingers  or  blunt- 
pointed  curved  scis- 
sors. With  the  remov- 
al of  the  tumor  the 
edges  of  the  wound 
are  to  be  fully  retract- 
ed and  any  bleeding 
points  secured  and 
compressed  or  ligated 
with  fine  catgut.  The 
skin  is  sutured  with- 
out drainage  or  over 
a  wick  of  gutta- 
percha tissue. 


. 

1       '! 

I           — *: 

■F 

WRRk  — : 

jjSftcc 

j4^ 

tB&  ■    •   ?^r 

^r 

1 

or- 

Fig.  105. — Lipoma  Shown  in  Figure  104  after  Re- 
moval. The  scale  of  inches  shows  its  length.  Its 
weight  was  25  ounces. 


SOLID   TUMORS  OF  THE   BREAST 

Hypertrophy. — Sometimes  during  adolescence  one  of  the 
breasts  will  become  abnormally  firm  and  larger  than  its  fellow 
and  rather  more  sensitive  to  pressure,  but  without  acute  pain. 
The  enlargement  is  diffuse  and  uniform,  and  there  is  no  adhesion 
of  the  breast  to  the  structures  either  beneath  or  superficial  to  it. 
Such  a  condition  has  a  tendency  to  resolve  in  the  course  of  time. 
This  return  to  the  normal  state  may  be  hastened  by  an  applica- 
tion of  ichthyol  ointment. 

Adenoma. — An  adenoma  or  an  adenofibroma  of  the  breast  is 
a  tumor  which  is  composed  of  a  localized  increased  growth  of 
glandular  and  fibrous  tissue.  There  are  several  types  of  such 
tumors  distinguishable  microscopically,  but  as  no  adenoma  is  com- 
posed only  of  glandular  tissue  and  no  fibroma  is  without  a  certain 
increase  in  glandular  tissue,  and  as  both  of  these  often  contain 
cysts,  an  exact  differential  diagnosis  between  them  is  not  always 
possible,  nor  has  it  more  than  a  pathological  significance.      The 


188  II  MORS   AND   DEFORMITIES   OF  THE  TRUNK 

tumor  is  generally  painless  and  is  first  noticed  by  the  patient 
durinu  ;i  hath  or  by  accident.  In  other  cases  there  is  a  little  pain 
in  the  tumor. 

Treatment. — Such  tumors  are  essentially  benign,  but  they 
may  also  change  their  type  of  growth  into  one  which  has  a  ten- 
dency to  spread  into  the  surrounding  tissues.  Hence  they  should 
be  removed,  or  at  least  carefully  watched  from  month  to  month 
in  order  to  be  sure  that  they  are  not  growing.  Puncture  with  a 
hypodermic  needle,  and  aspiration,  will  differentiate  between  a 
cystic  ami  a  solid  tumor  if  fluid  is  obtained.  A  negative  aspira- 
tion is  not  conclusive  (p.  1S3).  If  the  tumor  is  small  and  freely 
movable,  a  local  anesthetic  will  often  suffice;  but  otherwise,  and 
especially  if  the  patient  is  more  than  thirty  years  of  age,  she 
should  be  told  beforehand  of  the  possibility  of  a  major  opera- 
tion and  should  be  given  a  general  anesthetic.  If  the  growth  is 
found  to  be  malignant,  the  operation  should  be  continued  until 
it  includes  the  removal  of  the  breast  and  dissection  of  the  axillary 
and  clavicular  regions,  and  the  excision  of  one  or  both  pectoral 
muscles,  according  to  the  judgment  of  the  surgeon.  It  is  of  great 
assistance  at  such  times  to  have  a  pathologist  present,  who,  by  ma- 
king frozen  sections  of  the  excised  tumor,  can  determine  whether 
or  not  it  is  of  a  malignant  character.  In  general,  one  should  be 
very  suspicious  of  even  a  small,  freely  movable  tumor  which  has 
been  growing  but  a  few  months  and  is  painful.  This  is  especially 
the  case  if  the  patient  is  a  woman  more  than  thirty  years  of  age. 

The  Early  Diagnosis  of  Malignant  Tumors  of  the 
Breast. — The  treatment  of  malignant  tumors  of  the  breast  is 
quite  out  of  the  range  of  minor  surgery,  but  the  importance  of  a 
correct  diagnosis  in  the  early  stages  is  so  great  and  these  tumors 
are  so  often  first  seen  in  ambulatory  practise,  that  the  diagnostic 
points  should  be  emphasized. 

In  examining  a  patient's  breast  these  points  should  be  observed : 

Palpation. — The  patient  should  lie  flat  on  the  back  with  both 
breasts  exposed  for  the  sake  of  comparison.  Some  examiners  pre- 
fer to  have  the  patient  sit  upright,  but  the  recumbent  position  is 
better  for  a  thorough  examination.  Each  breast  should  then  be 
thoroughly  examined  by  rolling  its  substance  between  the  palmar 
surface  of  the  fingers  and  the  wall  of  the  thorax.  The  aim  of  the 
examination  is  to  determine  the  presence  of  any  nodules  or  other 


EARLY  DIAGNOSIS  OF  MALIGNANT  TUMORS  OF  THE  BREAST     189 

irregularities.  If  there  are  multiple  nodules  in  both  breasts,  the 
case  is  probably  one  of  chronic  mastitis.  The  same  is  probably 
true  of  multiple  nodules  in  one  breast,  for  if  these  are  cancerous, 
the  disease  will  of  necessity  be  far  advanced,  and  some  of  the  other 
symptoms  will  be  present.  A  single  nodule  in  one  breast,  or  in 
each  breast,  may  or  may  not  be  cancer.  It  should  be  further 
examined. 

Retraction  of  the  Shin. — This  is  best  shown  by  pushing  the 
breast,  but  not  the  tumor,  toward  the  suspected  part  of  the  skin. 
Retraction  of  the  skin,  under  these  circumstances,  is  one  of  the 
most  reliable  signs  of  cancer. 

A  Flattening  of  the  Normal  Curve  of  the  Breast  Over  the 
Tumor. — This  is  determined  by  sighting  across  it  with  the  eye 
on  the  same  level.     If  present  it  is  an  indication  of  malignancy. 

The  Presence  of  One  or  More  Enlarged  Glands  in  the  Axilla 
or  Between  the  Breast  and  Axilla. — This  is  not  one  of  the  earliest 
signs.  Both  axilla?  should  be  palpated.  If  the  glands  in  each  are 
equally  enlarged,  and  only  one  breast  contains  a  nodule,  the  axil- 
lary glands  are  presumably  non-cancerous. 

Palpation  of  the  axilla  is  best  performed  as  follows :  If  the 
left  axilla  is  to  be  palpated,  the  surgeon  stands  to  the  right  side 
of  the  patient.  He  lifts  her  left  arm  away  from  the  body,  and 
places  the  fingers  of  his  right  hand  well  up  in  the  left  axilla.  The 
arm  is  then  lowered,  or  brought  to  the  chest,  until  the  muscles  are 
relaxed.  The  surgeon  is  then  able  to  draw  his  fingers  with  the 
skin  of  the  axilla  back  and  forth  over  the  axillary  contents,  and 
to  feel  any  glands  which  are  present. 

Retraction  of  the  Nipple. — This  is  an  early  sign  of  cancer 
only  when  the  disease  begins  under  or  near  the  nipple.  In  other 
cases  the  growth  may  be  well  advanced  before  retracting  the  nipple. 

Hemorrhage  from  the  nipple,  either  spontaneous  or  occurring 
when  the  nipple  is  gently  squeezed,  is  a  symptom  of  value  if  there 
is  no  inflammation  or  other  obvious  explanation  of  its  occurrence. 

Failure  to  Withdraw  Fluid  through  a  Fine  Aspirating  Needle. 
— A  long  hypodermic  needle  is  sufficiently  large.  Fluid  indicates 
cystadenoma  in  most  cases,  though  some  cancers  contain  fluid. 

The  importance  of  carcinoma  of  the  breast  is  so  great  that, 
unless  the  examiner  can  be  sure  that  the  tumor  is  of  a  benign  char- 
acter, he  had  better  assume  it  to  be  malignant.     In  doubtful  cases 


190 


TUMOKS     VXD    DFFOKMITIFS   OF   TIM-:   TRUNK 


a  section  should  be  removed  for  microscopical  examination.     This 
may  be  successfully  done  with  cocain,  unless  the  patient  is  of  a 
nervous  disposition.     If  the  tumor  is  malignant,  an  extensive  re 
moval  of  breasl  and  axillary  gland  and  pectoral  muscles  and  fascia 
is  indicate*!. 

Carcinoma  beginning  in  the  nipple,  so-called  Paget's  disease, 
may  be  mistaken  for  eczema.  There  is  redness  and  scaliness,  fol- 
lowed by  a  shallow  ulceration  with  a  slightly  indurated  base  and 
narrow  indurated  margin.  It  is  inexcusable  to  neglect  such  a  con- 
dition, since  the  microscopic  examination  of  a  small  section  of 
the  affected  skin  will  reveal  the  true  nature  of  the  disease. 

Sarcoma. — Sarcoma  of  the  breast  differs  somewhat  from  car- 
cinoma in  its  gross  characteristics  inasmuch  as  it  usually  develops 

at  a  greater  distance 
from  the  nipple  and 
forms  a  diffuse  swelling 
deeply  situated  beneath 
the  skin,  and  often  ex- 
tending beyond  the  mar- 
gin of  the  breast  in  one 
or  more  broad  lobules 
before  the  surgeon's 
advice  is  sought  in  re- 
gard to  it.  It  grows 
rapidly,  without  pain, 
and  forms  new  nodules 
by  continuity  rather 
than  through  the  lym- 
phatic system;  hence 
the  axilla  may  be  en- 
tirely free  although  the 
tumor  has  grown  to  a 
diameter  of  two  inches 
or  more.  Such  a  free- 
dom of  the  axilla  is 
never  seen  in  carcinoma 
of  the  breast  of  a  similar 
size.  Sarcoma  grows  more  rapidly  than  carcinoma,  and  a  thor- 
ough and  early  removal  is,  therefore,  not  less  important. 


Fig.  106. — Epithelioma  of  the  Back  at  ax 
Early  Stage.  The  drawing  was  made  from 
the  tumor  after  removal.  Note  the  margin  of 
healthy  skin  on  all  sides  of  the  epithelioma. 


CARCINOMA   AND   SAKCOMA 


191 


Tuberculosis  may  be  mistaken  for  a  malignant  tumor  (see 
p.  ISO). 

Tumors  of  the  Male  Breast. — The  male  breast,  as  lias  al- 
ready been  said,   suffers  from  the  same  diseases  as  the  female 


Fig.   107.— Cross-section  of  the  Tumor   Shown   in  Figure    106.     Note  that  the 
tumor  has  not  yet  invaded  the  subcutaneous  tissue. 


breast.     As  the  fear  of  disfigurement  is  not  so  strong,  the  male 
patient  will  usually  seek  surgical  advice  soon  after  he  has  discov- 
ered the  tumor  of  the  breast.     Hence  the  prognosis  along  opera- 
tive lines  is  fairly  good.     If  neg- 
lected, however,  cancer  of  the  male 
breast  develops  in  fully  as  virulent 
a   manner   as   that    of  the   female 
breast,  forming  metastases,  extend- 
ing   inward    into    the    chest,    and 
causing   the   death    of   the    patient- 
from  exhaustion. 

MALIGNANT  TUMORS   OF  THE 
TRUNK 

Carcinoma  and  Sarcoma, — 

The  skin  of  the  trunk  may  be 
the  seat  of  malignant  tumors. 
They  have  no  especial  character- 
istics due  to  their  situation  (Figs. 
106  and  107).  If  seen  early, 
the  prognosis  after  removal  is  un- 
usually good,  since  the  surrounding 


Fig.  108. — Melanosarcoma  of 
Lower  Abdomen  of  Four 
Months'  Duration  Growing 
from  a  Mole  or  Soft  Wart. 
Patient  a  woman  aged  fifty-four 
years. 


192 


TUMORS  AND  DEFORMITIES   OF  THE  TRUNK 


Fig.  109. — Cyst  under  Scapula.     One  week's  duration. 
Due  to  subscapular  osteoma  and  traumatism. 


tissues  may  be 
sa  e  i-i  freed  wi  t  h 
much  freedom,  and 
hence  the  incision 
is  usually  carried 
wide  of  the  growl  h 
i  Fig.   ins). 

An  instructive 
mistake  in  diag- 
nosis is  connected 
with  the  patient 
shown  in  Figure 
109.  A  fluctuat- 
ing swelling  devel- 
oped soon  after  an 
injury.  Aspiration 
produced  a  bloody 
fluid, and  the  needle 
touched  abnormal 
bone.  A  diagnosis 
of  sarcoma  of  the 
scapula  was  made. 
"When  the  patient 
was  operated  upon 
it   was   found  that 


there  was  an  osteoma  of  the  scapula,  which  had  so  irritated  an 
adjacent  bursa  as  to  cause  an  accumulation  of  bloody  fluid. 


ACQUIRED    DEFORMITIES 

Displaced  Coccyx :  Coccygodynia.— Falls  upon  the  base 
of  the  spine  may  bend  the  coccyx  backward  or  forward,  or  otherwise 
injure  it.  It  may  then  become  the  seat  of  annoying  and  persistent 
j)ain,  called  coccygodynia.  The  projection  forward  of  the  bone 
may  interfere  with  defecation  and  prevent  its  easy  performance. 

The  history  given  by  the  patient  of  a  severe  fall,  followed  by 
pain  and  tenderness  which  have  never  entirely  disappeared,  should 
lead  at  once  to  a  physical  examination.  The  patient  either  stands 
or  lies  upon  his  side  with  knees  drawn  up.     The  surgeon  passes 


DISPLACED   COCCYX:   COCCYOODYNTA 


193 


the  well  lubricated  finger  high  up  into  the  rectum,  the  palmar 
surface  of  the  finger  being  directed  backward.  The  lower  part 
of  the  sacrum  and  the  coccyx  can  then  be  grasped  between  the 
forefinger  and  the  thumb.  The  size  and  direction  of  the  coccyx 
and  the  possible  range  of  motion  in  the  joint  between  it  and  the 
sacrum  should  be  noted;  also  the  existence  of  any  tender  spots. 

Treatment. — If  there  is  reason  to  attribute  the  existing  pain 
to  the  coccyx,  or  if  it  is  ankylosed  or  is  badly  deflected  and 
cannot  be  brought 
into  normal  relation 
to  the  sacrum  with- 
out pain,  the  coccyx, 
or  a  portion  of  it, 
should  be  removed. 
A  two  inch  median 
incision  is  sufficient 
for  the  purpose. 
The  patient's  bowels 
should  be  thorough- 
ly emptied  on  the 
previous  day.  At 
the  time  of  opera- 
tion the  skin  in  the 
vicinity  should  be 
thoroughly  cleansed, 
but  no  enema  given 
nor  rectal  examina- 
tion made  just  before 
operation.  Either 
local  or  general  an- 
esthesia is  satisfac- 
tory. The  incision 
is  started  at  the  level 
of  the  joint  between 
sacrum  and  coccyx 
and  extended  a  dis- 
tance of  not  more 
than  two  inches  toward  the  anus.  Skin  and  fat  are  divided  and 
the  coccyx  cut  down  upon.     The  soft  tissues  are  dissected  from  it 


Fig.  110. — Removal  of  a  Displaced  Coccyx.  The 
wound  necessary  for  its  removal  has  been  closed  by 
four  sutures.  Photograph  taken  four  days  after 
operation,  and  retouched  only  to  make  the  stitches 
and  wound  more  prominent.  The  coccyx  is  laid  on 
the  patient's  buttock. 


194  TUMORS   AND   DEFORMITIES  OF  THE  TRUNK 

posteriorly  and  along  both  sides.  The  joint  between  sacrum  and 
coccyx  is  opened  and  the  ligaments  divided.  If  the  bones  are 
ankylosed  they  must  be  separated  with  bone  shears  or  a  chisel. 
The  upper  end  of  the  coccyx  is  then  seized  and  pulled  backward. 
The  soft  tissues  in  front  of  the  coccyx  are  then  pushed  and  cut 
away  from  its  anterior  surface  and  the  bone  is  withdrawn  from 
the  wound.  In  this  manner  it  is  easy  to  avoid  wounding  even 
the  outer  coats  of  the  rectum.  Bleeding  is  controlled  by  pressure 
or  ligation,  the  cavity  is  obliterated  by  buried  sutures  of  catgut, 
and  the  skin  is  sutured  with  horsehair  or  fine  black  silk  (Fig.  110). 
If  any  drain  is  employed  it  should  be  a  small  gutta  percha  one, 
to  be  removed  in  two  days.  Primary  union  should  be  obtained. 
The  patient  should  lie  in  bed  for  two  days,  and  should  avoid  for 
'-dine  days  longer  any  sitting  or  other  posture  which  will  tend  to 
separate  the  edges  of  the  wound. 

Hernia.  — A  hernial  sac  is  a  protrusion  of  a  part  of  the  peri- 
toneum Through  an  opening  in  the  abdominal  wall.  In  this  sac 
there  may  or  may  not  be  found  portions  of  the  abdominal  organs. 
If  they  can  be  "  replaced  "  in  the  abdominal  cavity  the  hernia  is 
called  "  reducible."  Otherwise  it  is  an  "  irreducible  "  hernia. 
Such  reduction  may  be  impossible  on  account  of  altered  shape  of 
the  organs  in  the  sac,  its  "  contents,"  so-called,  or  on  account  of  ad- 
hesions which  have  formed  around  the  sac  and  its  contents.  The 
hernia  may  become  inflamed  as  a  result  of  traumatism,  etc.  This 
rarely  leads  to  suppuration.  It  may  produce  so  much  swelling  of 
the  hernial  contents  that  the  blood-vessels  which  supply  them  are 
occluded,  and  strangulation  results  (Strangulated  Hernia,  p.  198). 

A  hernia  may  exist  at  birth  or  develop  soon  afterward  in  an 
abnormally  weak  spot  in  the  abdominal  wall.  It  may  also  appear 
in  later  life,  either  suddenly,  following  some  crush  or  severe  strain, 
or  gradually,  as  the  result  of  oft  repeated  lesser  strains. 

The  subject  of  hernia,  and  especially  its  operative  treatment, 
is  exhaustively  discussed  in  works  upon  major  surgery.  Still,  the 
general  means  of  correct  diagnosis  and  the  ambulant  treatment  of 
patients  who,  for  one  reason  or  another,  cannot  be  operated  upon, 
are  here  in  place. 

General  Principles  of  Diagnosis. — A  patient  suspected  to 
have  a  hernia  should  be  examined  in  both  standing  and  recumbent 
postures. 


HERNIA  19.0 

Inspection  may  show  variation  in  size  at  different  limes  if  the 
hernia  is  reducible.  Peristaltic  movements  are  often  visible  in 
large  intestinal  hernise. 

Palpation  may  reveal  the  presence  of  intestinal  coils,  of  gurg- 
ling gas  and  fluid,  of  lumpy  omentum,  or  of  pasty. fecal  masses 
capable  of  being  indented. 

Compression,  when  the  patient  is  recumbent,  may  affect  the 
reduction  of  the  hernia. 

•  Percussion  will  bring  out  the  resonance  of  intestinal  coils  con- 
taining gas.  It  will  also  give  a  thrill  in  case  the  swelling  is  due 
to  a  hydrocele  or  a  cold  abscess. 

Auscultation  may  reveal  an  intestinal  gurgle  or,  in  rare  cases, 
an  aneurysmal  thrill. 

An  impulse  on  coughing  is  obtained  in  case  of  most  hernise. 
It  may  also  be  obtained,  though  less  marked,  in  case  of  a  large 
varicocele  or  in  case  of  a  hydrocele  which  extends  well  up  into 
the  inguinal  canal. 

Reduction  of  the  swelling  upon  compression  or  spontaneously 
when  the  patient  lies  down  is  very  significant  of  hernia,  but  may 
also  occur  with  an  imperfectly  descended  testis  or  a  cold  abscess. 

General  Principles  of  Treatment. — Operation  for  hernia, 
wherever  situated,  to  be  successful  must  accomplish  these  three 
steps :  1.  The  reduction  of  the  hernial  contents,  either  before  or 
after  the  sac  has  been  opened.  2.  The  closure  of  the  peritoneal 
cavity  at  the  normal  level.  The  sac  is  usually  tied  at  this  point, 
its  neck,  and  the  surplus  removed.  3.  The  approximation  by  firm 
sutures  of  the  damaged  wall  of  the  abdomen,  or  at  least  of  its 
strongest  part,  namely,  the  deep  fascia.  The  various  methods  of 
accomplishing  these  three  steps  vary  in  different  situations  and  in 
the  hands  of  different  operators.  They  are  fully  described  in  all 
surgical  text-books. 

If  the  condition  of  the  patient  and  the  character  of  the  hernia 
make  it  probable  that  the  three  steps  above  described  can  be  car- 
ried out  by  operation,  and  primary  union  attained,  operation 
should  be  advised.  It  is,  of  course,  absolutely  indicated  in  case 
of  strangulated  hernia  as  a  relief  of  acute  symptoms,  even  under 
circumstances  in  which  a  permanent  cure  of  the  hernia  is  not  to 
be  expected. 

A  truss  is  to  be  recommended  in  all  other  cases  of  reducible 
15 


191) 


Tl'MOHS   AXD   DEFORMITIES   OF   THE   TRUNK 


hernia.  A  patient  having-  an  irreducible,  inoperable  hernia  is  in- 
deed in  a  bad  state.  Some  of  them  gain  relief  by  an  operation 
which  changes  the  hernia  from  an  irreducible  to  a  reducible  one, 


Fig.  111. — Dorsal  Hernia  Following  Kraske's  Operation  for  Carcinoma  of 
the  Rectum.  The  hernia  developing  through  the  gap  in  the  posterior  pelvic 
wall  caused  by  the  removal  of  the  sacrum,  contained  the  greater  part  of  the 
small  intestine  and  the  sigmoid  flexure. 

so  that  a  truss  can  be  worn.  An  unusual  type  of  partly  reducible 
hernia  is  shown  in  Figure  111. 

The  symptoms  of  hernia  in  different  situations  vary  greatly. 
A  brief  description  is  therefore  given  of  each. 

Umbilical  Hernia. — Hernia  of  the  umbilicus  in  the  new-born  is 
extremely  common.  The  sac  is  usually  small  and  contains  intes- 
tine or  is  empty.  This  hernia  has  a  strong  tendency  toward 
recovery,  but  to  facilitate  this  end  it  should  be  constantly  kept 
pressed  back  by  means  of  a  cloth-covered,  wooden  button-mold 
and  a  short  strip  of  adhesive-  plaster.  This  should  be  changed 
every  day  or  every  second  day  after  the  infant's  bath,  but  before 
the  old  one  is  removed  the  new  one  should  be  prepared,  and  in 
the  interval  the  hernia  should  be  pressed  back  by  the  nurse's  fin- 
ger until  the  new  button  is  put  in  place.  The  plaster  should  extend 
in  a  different  direction  every  day  so  that  the  skin  may  not  become 
irritated.  If  treated  in  this  manner  the  great  majority  of  infan- 
tile umbilical  herniae  can  be  cured  in  a  few  months. 

Umbilical  hernia  in  the  adult  is  especially  common  in  stout 


HERNIA  197 

persons  of  middle  age.  It  first  appears  as  a  flabby  tumor  as  large 
as  the  terminal  joint  of  the  finger,  covered  with  normal  skin.  It 
is  usually  irreducible.  Its  contents  are  omentum.  As  it  grows 
the  sac  becomes  more  distended. ;  small  intestine  will  often  be  added 
to  the  omental  contents.  This  part  of  the  hernia  is  usually  re- 
ducible, at  least  for  a  consider;!  1  tie  period.  Such  a  hernia  fre- 
quently becomes  strangulated. 

A  truss  is  an  unsatisfactory  appliance  for  umbilical  hernia  of 
the  adult.  An  operation  should  be  performed  early,  if  possible 
before  intestine  is  involved. 

Inguinal  Hernia. — Inguinal  hernia  is  more  common  than  femo- 
ral hernia  both  in  the  male  (39  to  1)  and  female  (3  to  2)  ;  or,  to 
put  it  differently,  for  every  84  inguinal  hernias  in  the  male  there 
are  8  inguinal  hernias  in  the  female,  6  femoral  hernias  in  the 
female,  and  2  femoral  hernias  in  the  male.  It  is  usually  indirect, 
that  is  to  say,  the  omentum,  intestine,  etc.,  which  fills  its  sac  leaves 
the  abdomen  by  the  normal  route  of  the  inguinal  canal,  and  does 
not  burst  through  the  posterior  wall  of  the  inguinal  canal  to  the 
median  side  of  the  epigastric  artery  (direct  inguinal  hernia). 

Inguinal  hernia  may  be  congenital  or  acquired,  and  if  acquired 
it  may  develop  suddenly  as  the  result  of  a  crush  or  strain,  or  slowly. 

Symptoms. — These  symptoms  are  usually  present:  normal 
movable  skin;  underlying  tumor  giving  impulse  on  coughing, 
growing  smaller  or  disappearing  entirely  under  pressure  or  on 
lying  down;  enlarged  ring  and  inguinal  canal  evident  on  reduc- 
tion of  tumor;  reduced  tumor  does  not  reappear  when  patient 
stands  and  coughs  if  the  canal  is  blocked  by  the  surgeon's  finger ; 
no  true  fluctuation ;  opacity  to  transmitted  light. 

Possible  additional  symptoms  of  intestinal  hernia  are:  reso- 
nance on  percussion,  gurgling  on  manipulation,  indentation  of 
doughy  fecal  masses  in  large  intestine. 

Treatment.- — Treatment  by  operation  entails  only  a  slight 
risk,  and  is  generally  successful.  It  should  therefore  be  advised 
in  the  case  of  all  healthy  children  and  active  adults.  Treatment 
by  truss  is  advisable  for  feeble  and  aged  persons  and  for  those 
whose  tissues  in  the  inguinal  region  are  so  thinned  by  previous 
unsuccessful  operation  that  they  cannot  be  made  to  withstand  the 
intra-abdominal  pressure. 

A  truss  is  a  pad  held  firmly  against  the  lower  part  of  the 


19S  TUMORS  AND   DEFORMITIES   OF  THE  TRUNK 

inguinal  canal  to  prevent  the  exit  of  the  omentum,  etc.,  from  the 
abdominal  cavity.  It  has  been  well  compared  to  the  stopper  of  a 
bottle.  Opinions  differ  as  to  the  best  form  of  truss.  A  satisfac- 
tory truss  is  one  which,  with  a  minimum  of  pressure  and  without 
causing  the  patient  any  pain,  prevents  the  hernial  contents  from 
entering  the  hernial  sac. 

The  hernia  must  be  fully  reduced  before  a  truss  is  applied. 
This  is  best  done  when  the  patient  lies  on  bis  back.  A  truss 
should  never  be  applied  to  a  hernia  which  is  only  partially  re- 
ducible. It  will  rarely  succeed  in  keeping  back  the  rest  of  the 
hernial  contents,  and  by  its  pressure  on  the  part  already  in  the 
sac  it  will  cause  pain  and  possibly  serious  inflammation,  or  even 
gangrene. 

A  truss  is  rarely  needed  in  case  of  a  very  young  infant;  but 
before  the  child  is  old  enough  to  walk  it  should  be  fitted  with  a 
truss  or  should  be  operated  upon.  Operation  is  advisable  for  large 
congenital  hernia?,  as  cure  is  improbable  when  the  neck  of  the  sac 
is  so  wide.  If  the  tunica  vaginalis  communicates  with  the  peri- 
toneal cavity  by  a  rather  narrow  passage,  and  the  contents  of  the 
hernial  sac  can  be  reduced  into  the  abdomen  without  dragging  the 
testicle  upward,  a  truss  may  cure  the  patient  in  the  course  of  a 
few  years.  For  this  purpose  it  should  be  worn  constantly  day 
and  night,  as  crying  no  less  than  walking  will  force  the  abdominal 
organs  into  the  hernial  sac.  As  the  child  grows  older  the  truss 
may  be  left  off  at  night,  and  if  the  neck  of  the  sac  becomes  oblit- 
erated the  truss  need  only  be  worn  during  exercise,  and  finally 
not  at  all.  A  cure  is  sometimes  obtained  from  a  truss  in  adult 
life,  but  is  far  less  likely  after  the  patient  has  attained  his  growth. 

Femoral  Hernia. — In  femoral  hernia  the  protrusion  of  abdom- 
inal contents  is  under  Poupart's  ligament  and  through  the  femoral 
ring.  Such  a  hernia  is  usually  small,  and  this  fact,  added  to  the 
tortuous  course  of  the  canal,  sometimes  obscures  the  impulse  on 
coughing  and  renders  diagnosis  difficult.  An  enlarged  lymphatic 
gland,  with  which  femoral  hernia  is  often  confounded,  if  unilat- 
eral has  almost  always  an  evident  cause  in  some  scratch  or  cut 
of  the  foot  or  leg. 

Femoral  hernia  should  always  be  treated  by  operation. 

Strangulated  hernia  always  requires  treatment  in  bed  or  im- 
mediate operation,  but  most  of  the  patients  are  seen  by  a  physician 


ASCITES-PARACENTESIS  199 

while  they  are  still  walking  about,  so  that  the  symptoms  should 
be  fixed  clearly  in  mind,  ready  for  instant  service.  They  vary 
according  to  the  character  of  the  compressed  organ.  Omentum 
may  become  strangulated  and  give  only  moderate  pain  and  dis- 
ability for  days.  Large  intestine,  and  even  small  intestine  if  only 
a  part  of  the  circumference  of  the  bowel  is  constricted,  give  the 
same  symptoms  in  a  more  marked  degree,  plus  vomiting  and  more 
or  less  distention.  If  the  lumen  of  the  small  intestine  is  com- 
pletely obstructed  there  is  repeated  vomiting,  becoming  brown  and 
foul-smelling  ("  fecal  "),  and  absolute  stoppage  of  the  bowels  even 
for  gas. 

The  various  hernial  orifices  should  be  examined  in  all  cases 
of  intestinal  obstruction. 

Treatment. — Dorsal  decubitus,  the  steady  pressure  of  a  pad 
of  unbleached  cotton  and  a  spica  bandage,  and  the  cold  of  a  big 
ice-bag  will  cause  the  reduction  of  many  strangulated  hernias. 
This  treatment  should  be  tried  only  in  the  early  hours  of  strangu- 
lation, lest  one  succeed  in  reducing  a  loop  of  intestine  already 
gangrenous.     In  most  cases  immediate  operation  is  indicated. 

Ascites  -  Paracentesis. — The  causes  of  simple  ascites  are 
medical,  and  its  treatment  is  essentially  so,  except  in  one  respect, 
namely,  paracentesis  or  the  puncture  of  the  abdomen  for  with- 
drawal of  the  extravasated  serum,  for  the  peritoneal  cavity  may 
become  so  distended  with  serum  that  it  is  desirable  to  withdraw 
the  whole  or  a  part  of  the  fluid.  This  slight  operation  is  almost 
free  from  risk.  It  is  best  performed  in  the  following  manner:  A 
point  is  selected  two  or  three  inches  below  the  umbilicus,  either  in 
or  near  the  median  line,  or  well  to  the  outer  edge  of  the  rectus 
muscle.  Thus  one  chooses  the  thinner  parts  of  the  abdominal  wall 
and  avoids  the  large  vessels  (deep  epigastric)  which  lie  beneath 
the  outer  part  of  the  rectus  muscle.  In  making  the  puncture  one 
naturally  avoids  any  visible  veins.  The  patient  should,  if  possible, 
be  in  a  sitting  posture,  with  the  bladder  empty. 

After  cleansing  the  skin,  the  sensation  may  be  dulled  by  ethyl 
chlorid  or  by  the  injection  of  a  few  drops  of  a  two  per  cent  solu- 
tion of  cocain.  A  trocar  and  cannula  is  pushed  quickly  through 
the  abdominal  wall.  If  the  peritoneal  cavity  is  so  distended  with 
fluid  that  the  wall  is  tense,  the  puncture  is  an  easy  one;  if  the 
distention  is  less,  one  must  proceed  with  more  care.     It  will  then 


200 


TUMORS    AND    DEFORMITIES    OF    THE    TRUNK 


be  found  of  advantage  to  turn  the  instrument  hack  and  forth 
while  pushing  it  forward,  exactly  as  one  uses  an  awl.  In  either 
case  it  is  well  to  hold  the  forefinger  against  the  side  of  the  instru- 
ment as  a  guide  to  the  depth  to  which  it  is  plunged  (Fig.  112). 


Fig.  112. — Method  of  Holding  Trocar  and  Cannula  before  Plunging  it  Through 
the  Abdominal  Wall.  The  forefinger  acts  as  a  guide  to  control  the  depth  of 
puncture.     A  smaller  trocar  and  cannula  are  also  shown. 

The  size  of  the  cannula  employed  varies  according  to  circum- 
stances. If  the  puncture  is  made  merely  for  diagnostic  purposes, 
or  if  the  quantity  of  fluid  to  he  removed  is  small,  one  naturally 
selects  a  small  cannula,  possibly  as  small  as  No.  6  French.  If, 
on  the  other  hand,  several  quarts  are  to  be  removed,  as  is  fre- 
quently the  case  in  hepatic  cirrhosis,  one  should  select  an  instru- 
ment not  smaller  than  12  or  11  French.  The  elasticity  of  the 
tissues  will  invariably  close  the  opening  in  a  short  time  after  the 
cannula  is  removed. 

When  the  trocar  is  withdrawn  serous  fluid  should  flow  out  in 
a  stream.  If  it  does  not,  the  end  of  the  cannula  has  not  entered 
the  peritoneal  cavity,  or  else  it  is  blocked  by  omentum  or  intes- 
tine. An  attempt  should  be  made  to  push  the  cannula  further 
inward.  If  this  is  impossible  its  end  is  not  within  the  peritoneal 
cavity.  In  this  case  the  trocar  should  be  reinserted  in  the  cannula, 
and  the  combined  instrument  pushed  further  inward,  or  a  new  site 
for  the  puncture  may  be  selected. 


SPINA  BIFIDA  201 

If  fluid  does  not  flow,  although  the  cannula  can  be  pushed 
further  inward,  or  if  a  flow  of  fluid  is  suddenly  stopped,  it  is 
evident  that  something  has  obstructed  the  inner  end  of  the  can- 
nula. This  may  be  overcome  by  tilting  the  cannula,  or  by  shift- 
ing the  position  of  the  patient,  or  by  inserting  a  stiff  wire,  first 
sterilized,  through  the  cannula  to  keep  back  the  obstructing  mass. 
Cannulas  have  been  made  with  lateral  openings  in  order  to  pro- 
vent  this  annoyance,  but  it  is  rarely  a  troublesome  one. 

The  risk  of  wounding  intestine  or  omentum  is  a  very  slight 
one.  Indeed,  this  accident  can  scarcely  occur  unless  there  are  firm 
adhesions  at  the  point  of  puncture.  In  case  of  repeated  puncture 
it  is  therefore  well  to  select  a  new  site  each  time. 

Some  advise  the  incision  of  the  skin  with  a  narrow  scalpel. 
This  makes  the  puncture  easier,  but  it  is  an  unnecessary  precau- 
tion unless  the  trocar  is  dull. 

Whether  all  the  fluid  should  be  removed  at  one  sitting  will 
depend  on  the  general  condition  of  the  patient.  In  the  majority 
of  instances  there  is  no  objection  to  drawing  it  all  off. 

Should  the  instrument  puncture  a  vein  or  an  artery  in  its 
passage  through  the  abdominal  wall,  hemorrhage  may  follow  the 
withdrawal  of  the  cannula.  It  usually  ceases  in  a  minute  or  two, 
but  if  there  is  any  doubt  about  it  a  little  more  cocain  should  be 
injected,  a  longitudinal  incision  made,  the  wound  retracted,  and 
the  vessel  ligated.  This  can  be  done  without  opening  the  peri- 
toneal cavity. 

The  risk  of  infection  following  paracentesis  is  slight.  It  has 
doubtless  been  performed  hundreds  of  times  without  any  aseptic 
precaution,  and  yet  without  bad  result ;  but  this  is  no  warrant  for 
negligence.  When  the  cannula  has  been  withdrawn  the  opening 
should  be  sealed  with  a  little  cotton  and  collodion,  or  if  the  serum 
continues  to  trickle  from  the  wound,  a  pad  of  sterile  gauze  should 
be  applied  and  changed  as  often  as  it  becomes  saturated. 

CONGENITAL   DEFORMITY 

Spina  Bifida. — The  only  important  congenital  deformity  of 
the  trunk  amenable  to  treatment  is  spina  bifida.  (For  congenital 
cysts  and  sinuses,  see  p.  181.) 

Spina  bifida  is  a  failure  of  development  in  which  the  bony 


202  TUMORS   AND    DEFORMITIES   OF   THE   TRUNK 

processes  of  one  or  more  vertebrae  are  not  united  posteriorly.  This 
defecl  is  mosl  often  seen  in  the  lumbar  or  sacral  region.  The 
cleft  may  extend  to  the  surface,  in  which  case  the  spinal  canal 
will  be  open,  or  it  may  be  closed  by  sonic  of  the  normal  structures, 
even  though  the  epidermis  is  wanting;  or  it  may  be  entirely  cov- 
ered with  skin.  In  the  marked  eases  of  defect,  in  which  the  spinal 
canal  is  either  open  at  birth  or  becomes  so  by  ulceration  of  the 
imperfectly  formed  soft  tissues,  infection  soon  extends  into  the 
canal,  and  the  child  dies  of  meningitis.  In  the  less  marked  eases, 
in  which  there  is  a  firmer  posterior  wall  made  up  of  the;  mem- 
branes of  the  cord,  and  possibly  an  intact  skin,  there  exists  an 
accumulation  of  serous  fluid,  giving  a  rounded  tumor,  which  fluc- 
tuates on  palpation.  The  cavity  of  such  a  cyst  may  communicate 
with  the  central  canal  of  the  spinal  cord,  or  more  often  with  the 
spaces  between  the  cord  and  its  membranes.  If  the  latter  is  the 
case,  the  tumor  is  a  meningocele.  In  some  cases  of  spina  bifida  a 
certain  amount  of  paralysis  exists,  due  to  developmental  defect  at 
the  affected  point  of  the  spine.  It  should,  however,  be  borne  in 
mind  that  there  may  be  other  associated  developmental  defects 
elsewhere  in  the  brain  or  spinal  cord. 

Spina  bifida  is  amenable  to  treatment  by  operation  if  the  de- 
fect in  the  spinal  column  is  not  too  large.  Prognosis  is  most  favor- 
able when  there  is  a  simple  meningocele,  with  a  small  internal 
opening.  But  even  in  such  a  case  the  greatest  care  must  be  taken 
to  prevent  infection  of  the  wound,  for  this  will  almost  certainly 
lead  to  death  by  septic  meningitis.  Similar  care  should  be  exer- 
cised in  nonoperated  cases  to  prevent  ulceration  and  rupture.  The 
child  should  be  kept  off  of  its  back,  so  that  the  surface  of  the  tumor 
may  never  become  contaminated  with  urine  or  feces,  and  may  be 
protected  from  pressure.  Treatment  by  injection  and  by  ligation 
has  been  at  times  successful  in  curing  a  spina  bifida,  but  the  risks 
and  uncertainties  are  such  that  their  performance  at  the  present 
day  is  not  to  be  advised. 

If  the  communication  between  the  cavity  of  a  meningocele  and 
that  of  the  spinal  column  is  very  small,  it  may  become  obliterated 
before  birth,  so  that  a  solid  tumor,  composed  of  fat  or  fibrous 
tissue,  may  exist  instead  of  a  cystic  one.  In  removing  such  a 
growth  the  possibility  of  opening  the  spinal  canal  should  be  kept 
in  mind. 


SECTION  IV 

AFFECTIONS   OF   THE   GEJSttTO-UPJNARY 

ORGANS 


CHAPTER    VIII 

INJURIES    AND    INFLAMMATIONS    OF  THE    MALE 
GENITO-URINARY  ORGANS 

INJURIES 

Contusion. — Blows  upon  the  penis  and  testicles  are  very  com- 
mon. Owing  to  the  sensitiveness  of  these  structures  they  produce 
a  degree  of  shock  out  of  proportion  to  the  local  evidence  of  injury. 
The  freedom  of  motion  of  these  parts  often  saves  them  from  severe 
injury.  Swelling,  especially  of  the  testicle,  may  be  considerable 
even  after  a  slight  injury.  Deep  injury  may  result  in  extensive 
extravasation  of  blood,  with  or  without  rupture  of  the  erectile 
bodies  or  of  the  urethra,  or  it  may  be  accompanied  by  hemorrhage 
into  the  tunica  vaginalis,  known  as  hematocele ;  while  a  still 
deeper  injury  may  cause  rupture  of  the  bladder,  intraperitoneally 
or  extraperitoneally. 

Diagnosis. — The  diagnosis  of  the  lighter  forms  of  injury  is 
usually  not  difficult.  An  inspection  of  the  parts  supplemented  by 
palpation  will  usually  reveal  the  extent  of  the  trauma.  Owing  to 
the  laxity  of  the  tissues  extravasated  blood  spreads  rapidly,  while 
edema  finds  little  restraint  and  may  quickly  alter  the  normal  ap- 
pearance of  the  penis.  The  diagnosis  of  the  deeper  injuries  is 
considered  under  the  separate  titles. 

Treatment. — This  consists  in  rest,  support  of  the  parts,  and 
cooling  applications.  Compresses  wet  with  a  mixture  of  alcohol 
and  water  or  fluid  extract  of  hamemelis,  should  be  applied  and 
kept  moist.  ISTo  impervious  substance  should  be  used  to  cover 
them,  as  the  cooling  effect  of  free  evaporation  adds  greatly  to  the 
comfort  of  the  patient  in  most  cases.  Or  the  wet  compresses  may 
be  covered  with  flannel,  oil  silk,  or  gutta  percha  tissue,  and  the 

203 


204        INJURIES  OF  THE  .MALE  GENITOURINARY  ORGANS 

dressing  kept  cold  by  an  ice-bag  placed  alongside  of  it.  While 
the  patient  is  in  bed  the  testicles  should  be  supported  on  a  folded 
towel  placed  across  the  thighs.  As  soon  as  he  is  up  the  weight  of 
a  swollen  testicle  should  be  taken  off  of  the  cord  by  a  suspensory 
bandage.  .If  there  is  subcutaneous  hemorrhage  which  is  not  con- 
trolled by  these  measures,  or  if  an  erectile  body  has  been  ruptured, 
an  incision  should  be  made  and  the  bleeding  vessel  secured  or  the 
fibrous  envelope  sutured. 

Contusion  of  the  testicle  is  apt  to  be  followed  by  pain,  more 
noticeable  toward  night  or  after  exertion.  An  ointment  contain- 
ing belladonna  or  ichthyol  should  be  applied  and  the  testicles  sup- 
ported by  a  suspensory  bandage. 

Hematoma:  Hematocele. — The  blood  from  a  ruptured  ves- 
sel usually  spreads  quickly  throughout  the  loose  subcutaneous  tis- 
sue. In  this  manner  penis  and  scrotum  may  in  a  short  time  be- 
come a  dark  garnet  or  magenta  in  color.  In  other  cases  the  blood 
may  accumulate  in  one  place  and  so  form  a  hematoma.  This  is 
most  likely  to  occur  if  the  ruptured  vessel  empties  into  the  tunica 
vaginalis.  Such  a  condition  is  called  a  hematocele.  It  may  exist 
without  any  discoloration  of  the  skin.  It  gives  rise  to  a  smooth, 
tense  fluctuating  swelling,  the  size  and  shape  of  the  distended 
tunica  vaginalis.  Often  the  swollen  testicle  is  lost  in  the  mass  of 
clotted  blood  so  that  it  cannot  be  distinguished.  A  hematocele 
can  be  differentiated  from  a  hydrocele  by  its  rapid  formation,  by 
its  opacity  to  transmitted  light ;  from  a  hernia  by  its  irreducibil- 
ity,  by  the  absence  of  an  impulse  on  coughing,  and  by  the  fact  that 
the  swelling  does  not  extend  into  the  inguinal  canal. 

Tkeatment. — Extensive  hemorrhage  in  the  tissues,  if  diffuse, 
will  take  care  of  itself.  If,  on  the  other  hand,  there  is  a  large 
hematoma,  an  incision  should  be  made  into  it  and  the  blood  clot 
taken  out  and  the  wound  closed.  The  best  time  for  the  removal 
of  the  effused  blood  by  aspiration  is  a  few  days  after  the  accident, 
when  the  cutaneous  effects  of  contusion  will  have  subsided  and  the 
blood  clot  will  have  softened  somewhat.  If  operation  is  not  per- 
formed the  blood  clot  will  remain  for  months  before  it  is  entirely 
absorbed,  even  if  it  does  not  act  as  a  foreign  body  and  cause  necro- 
sis of  the  overlying  skin.  Such  an  operation  is  free  from  risk  if 
asepsis  is  rigidly  observed.  The  wound  may  be  sealed  with  a  cot- 
ton-collodion dressing. 


PARAPHIMOSIS  205 

"Fracture  "  of  the  Penis. — A  too  violent  effort  in  coitus,  as 
well  as  some  form  of  direct  violence,  may  rupture  one  of  the  erec- 
tile bodies  of  the  engorged  penis.  The  result  is  the  immediate 
escape  of  blood  from  the  fibrous  sheath  in  which  the  erector  vessels 
are  confined,  producing  a  flabby  and  distorted  penis.  If  there  is 
also  a  wound  in  the  skin  the  blood  may  escape  externally. 

Treatment. — The  non-operative  treatment  consists  in  the  ap- 
plication of  cold  and  a  firm  bandage.  The  results  are  often  unsat- 
isfactory, as  is  to  be  expected,  when  one  considers  the  amount  of 
the  effused  blood  and  the  structure  of  the  penis  itself — so  ill 
adapted  to  a  firm  bandage.  The  blood  clots  are  not  fully  absorbed 
for  a  long  time,  scar  tissue  forms,  and  the  deformity  is  often  per- 
manent. 

The  modern  surgical  treatment  in  these  cases  is  an  immediate 
exposure  of  the  ruptured  tissues  by  a  longitudinal  incision,  con- 
trol of  the  hemorrhage  by  ligature  or  otherwise,  suture  of  the 
fibrous  sheath  with  fine  chromic  catgut,  and  suture  of  the  skin- 
wound  with  horsehair  or  fine  silk.  With  reasonable  care,  wounds 
in  the  penis  heal  aseptically.  The  operation  may  be  performed 
with  a  local  or  general  anesthetic.  The  blood  supply  in  the  organ 
may  be  controlled  during  the  operation  by  an  elastic  rubber  band 
wound  around  the  root  of  the  penis.  This  will  also  facilitate  local 
anesthesia  by  limiting  the  diffusion  of  the  solution  employed. 
The  rubber  bandage  should  be  removed  before  the  skin  is  sutured 
in  order  to  test  the  control  of  deep  hemorrhage. 

Paraphimosis. — If  a  too  tight  foreskin  is  fully  retracted 
over  the  corona  of  the  glans,  the  head  of  the  penis  swells  so  that 
it  is  difficult  to  draw  the  foreskin  down  over  it.  The  longer  the 
condition  lasts  the  more  difficult  it  is  to  relieve  it.  Soon  the  fore- 
skin becomes  edematous,  and  this  adds  to  the  difficulty  of  reduc- 
tion.    The  ability  to  urinate  is  usually  not  impaired. 

Treatment.- — To  reduce  a  retracted  foreskin  it  should  be 
grasped  with  the  thumb  and  finger  of  either  hand  at  opposite 
points  of  its  circumference,  the  thumbs  being  nearer  the  glans 
penis  and  firmly  fixed  upon  the  foreskin  as  close  to  the  corona  as 
possible.  If  the  skin  is  slippery  it  should  first  be  wiped  dry  and 
clean.  Most  of  the  obstruction  to  reduction  is  on  the  dorsal  side 
of  the  penis,  and  hence  the  points  at  which  the  foreskin  is  seized 
should  be  situated  a  little  more  dorsally  than  ventrally.     Steady 


!>()(}        INJURIES  OF  THE  MALE  GENITO-URINARY  ORGANS 

tension  should  now  be  exerted,  the  two  hands  pulling  in  slightly 
divergent  lines  in  order  to  assist  in  relieving  the  constriction  of 
the  foreskin  over  the  corona. 

If  the  efforts  a1  reduction  arc  unsuccessful  the  surgeon  may 
bandage  the  penis  with  a  thin  rubber  bandage,  ami  so  reduce  swell- 
ing, or  he  may  use  a  gauze  bandage  and  saturate  it  with  an  astrin- 
gent solution  and  leave  it  in  place  a  few  hours.  This  treatment 
may  so  reduce  the  swelling  that  the  foreskin  can  be  drawn  over  the 
glans.  If  the  condition  of  the  parts,  such  as  marked  congestion 
or  threatened  gangrene,  forbids  delay,  the  foreskin  should  be  di- 
vided dorsally  by  an  incision  parallel  to  the  long  axis  of  the  penis 
(see  p.  246).  Reduction  Avill  then  be  easy.  The  operation  should 
be  completed  by-  suture,  but  the  longitudinal  incision  should  be 
sutured  laterally,  or  a  partial  or  complete  circumcision  may  be 
at  once  performed.  If  a  tight  paraphimosis  is  left  to  itself  a  spon- 
taneous reduction  may  take  place  or  the  retracted  skin  may  become 
adherent  in  its  new  relations  so  that  reduction  is  impossible;  or  it 
may  lead  to  gangrene  of  either  the  constricting  skin  or  of  the  head 
of  the  penis. 

Neuralgia  of  Testicle. — Violent  coitus  may  produce  neu- 
ralgia of  the  testicle,  and  even  a  swelling  of  the  organ,  which 
the  patient  calls  a  "  strain."  It  is  best  treated  by  a  suspensory 
bandage,  by  the  application  of  cooling  lotions,  or  of  belladonna 
or  ichthyol  ointment,  and  by  the  avoidance  of  sexual  excitement 
until  the  symptoms  have  disappeared.  If  the  patient  is  troubled 
wTith  erections  during  sleep,  large  doses  of  bromid  of  potash  should 
be  given  during  the  afternoon  and  evening,  and  the  bowels  should 
be  thoroughly  emptied.  In  many  cases  of  neuralgia  of  the  testicle 
of  sexual  origin,  relief  follows  the  occasional  passage  of  a  steel 
sound  through  the  deep  urethra. 

Whenever  possible,  these  patients  should  be  encouraged  to  take 
up  normal  sexual  life,  for  frequently  and  unjustly  they  mistrust 
their  power  to  enter  into  a  happy  marriage.  Experience  has  re- 
peatedly shown  that  all  the  neuralgic  symptoms  disappear  in  a  few 
weeks  after  marriage. 

Foreign  Bodies  of  the  Penis  and  Urethra. — A  special 
form  of  injury  of  the  penis  is  caused  by  slipping  a  ring  over  the 
end  of  the  organ.  The  congestion  which  results  swTells  the  glans 
so   that   it  is   impossible  to  remove   the  ring.      This  congestion 


FOREIGN    BODIES   OF   THE   PENIS   AND   URETHRA         207 

increases  as  time  goes  by  and  if  surgical  aid  is  not  sought  gan- 
grene will  follow.  But  before  this  occurs  the  ring  may  be  so 
buried  in  the  edematous  skin  as  to  be  invisible  unless  a  careful 
examination  is  made. 

Foreign  bodies  are  also  passed  up  into  the  urethra  for  pur- 
poses of  sexual  excitement.  They  sometimes  slip  from  the  grasp 
of  the  individual  and  pass  wholly  within  the  meatus. 

The  symptoms  vary  according  to  the  nature  of  the  foreign 
body  lodged  in  the  urethra.  If  this  is  smooth  there  may  be  no 
serious  symptoms  until  a  calculus  forms  about  it  some  weeks  later, 
or  infection  of  the  urethra  or  bladder  may  be  caused.  This  is 
more  likely  to  follow  the  introduction  of  a  sharp  object  such  as  a 
pin.  If  the  urethra  is  torn,  the  swelling  may  make  urination  dif- 
ficult or  impossible. 

Treatment. — A  ring  which  has  been  passed  over  the  penis 
should  be  filed  or  cut  in  two  places  and  removed.  Usually  a  thin 
strip  of  steel  can  be  passed  under  the  ring  at  some  point  in  its 
circumference  in  order  to  protect  the  penis  from  the  file. 

The  extraction  of  a  foreign  body  from  the  urethra  is  often 
extremely  difficult.  If  ^  the  body  lies  near  the  meatus  it  may  be 
seized  and  drawn  outward  by  a  pair  of  thin  forceps.  Before  at- 
tempting the  seizure,  firm  pressure  should  be  made  upon  the 
urethra  near  the  base  of  the  penis  so  as  to  prevent  the  foreign 
body  from  slipping  upward  into  the  bladder.  If  the  object  is 
sharp-pointed,  as  a  pin,  and  the  point  is  toward  the  meatus,  it 
may  be  pushed  out  through  the  wall  of  the  urethra  and  the  penis, 
reversed,  and  pushed  back  into  the  urethra,  so  that  the  head  is 
toward  the  meatus.  The  head  can  then  be  grasped  with  forceps 
and  the  pin  extracted.  If  the  foreign  body  is  not  sharp-pointed, 
as,  for  instance,  a  slate  pencil,  it  may  be  extracted  by  pinching  the 
urethra  firmly  above  its  upper  end  and  crowding  the  penis  upward 
past  its  lower  end.  The  lower  end  is  then  grasped  through  the 
penis,  and  traction  is  made  in  order  to  stretch  the  urethra  to  its 
fullest  extent.  While  thus  stretched  the  urethra  is  again  pinched 
above  the  upper  end  of  the  slate  pencil,  and  the  penis  again 
crowded  up  from  below.  By  this  means  the  foreign  body  can  be 
brought  out  of  the  meatus.  This  method  can  be  easily  demon- 
strated by  slipping  a  slate  pencil  into  a  piece  of  rubber  tubing 
whose  caliber  is  great  enough  to  receive  it  readily. 


208        IXJl'KIES  OF  THE  MALE  GENITOURINARY  ORGANS 

If  the  foreign  body  cannot  be  extracted  through  the  meatus,  an 
incision  should  be  made  directly  down  upon  it  to  permit  of  its 
prompt  removal.  The  wound  of  the  urethra  should  be  sutured  at 
once,  and  also  the  wound  of  the  skin  unless  infection  exists,  in 
which  case  drainage  may  be  advisable. 

Foreign  Bodies  in  Bladder. — A  foreign  body  which  finds 
its  way  into  the  male  bladder,  either  through  the  urethra  or  by 
penetration  of  the  wall  of  the  bladder,  usually  becomes  tncrusted 
with  urinary  salts  in  a  short  time. 

The  symptoms  depend  more  or  less  on  the  nature  of  the  object, 
whet  her  it  has  sharp  angles,  etc.  They  are  in  general  pain,  espe- 
cially at  the  end  of  micturition;  vesical  irritability,  as  shown  by 
pain  when  the  body  is  jarred  and  by  frequent  micturition;  and  an 
admixture  of  blood  with  the  urine,  and  perhaps  the  passage  of  a 
couple  of  drops  of  pure  blood  at  the  end  of  the  act.  The  foreign 
body  may  cause  a  sudden  stoppage  of  the  urinary  stream  during 
micturition.  If  a  foreign  body  remains  in  the  bladder  for  some 
time,  the  urine  may  become  ammoniacal.  The  symptoms  given 
are  also  the  symptoms  of  calculus. 

The  diagnosis  can  be  made  from  the  symptoms ;  also  by  means 
of  a  short,  sharply  curved  steel  sound  called  a  stone  searcher ;  in 
some  instances  by  the  X-ray,  and  in  some  by  the  eystoscope. 

Treatment. — The  removal  of  the  foreign  body  is  the  essential 
of  treatment.  This  usually  requires  an  incision  into  the  bladder. 
The  suprapubic  route  is  the  method  of  choice. 

Wounds. — All  wounds  of  the  external  genitals  should  be 
treated  by  thorough  cleansing,  control  of  hemorrhage  by  ligature, 
suture  of  both  superficial  and  deep  structures,  and  if  necessary 
drainage.  The  tendency  of  contused  wounds  to  bleed  subcutane- 
ously  is  very  marked,  on  account  of  the  free  blood-supply  and 
lax  tissues.  All  blood  clots  should  be  evacuated,  and  the  spaces  in 
which  they  lie  should  be  suitably  drained. 

Rupture  of  Urethra. — This  may  be  complete  or  partial.  It 
is  usually  due  to  a  fall  astraddle  of  some  hard  object  or  to  a  kick 
in  the  perineum.  By  this  violence  the  bulbous  urethra  is  pressed 
against  the  edge  of  the  pubis  and  divided. 

The  symptoms  are  pain  and  swelling  at  the  seat  of  injury,  and 
usually  bleeding  from  the  meatus.  There  will  be  either  inability 
to  pass  water  or  painful,  dribbling  micturition,  the  urine  contain- 


RUPTURE   OF   URETHRA  209 

ing  blood,  or,  as  is  usually  the  case,  the  passage  of  a  little  urine 
from  the  meatus  and  the  extravasation  of  a  certain  amount  of 
urine  about  the  point  of  rupture.  If  there  is  an  external  wound 
the  urine  will  escape  from  it.  If  not,  the  passage  of  an  olive- 
tipped  bougie  will  usually  establish  the  diagnosis.  If  the  urethra 
is  torn  clear  across  the  bougie  will  fail  to  enter  the  vesical  por- 
tion, or  if  it  is  only  partially  torn  the  rent  in  the  membrane 
may  be  felt.  Sometimes  the  break  may  be  felt  by  external  pal- 
pation. A  doubtful  diagnosis  will  usually  exist  only  in  those 
instances  in  which  the  urethra  is  divided  without  the  skin  being 
broken. 

Treatment. — The  treatment  for  all  cases  of  partial  or  com- 
plete rupture  of  the  urethra  is  immediate  incision  and  suture. 
Only  the  simplest  cases  of  rupture  of  the  pendulous  portion  may 
be  left  to  heal  of  themselves.  If  the  divided  ends  are  retracted, 
or  if  a  portion  of  the  urethra  is  so  badly  bruised  that  it  has  to 
be  cut  away,  suture  of  the  urethra  is  still  possible  by  loosening  it 
from  its  attachments  a  little  distance  in  both  directions.  An  inch 
of  the  urethra  has  been  resected  and  the  urethra  sutured  with  com- 
plete success.  For  this  purpose  fine  silk  should  be  used,  and  only 
two  or  three  of  the  sutures  should  pass  clear  through  the  mucous 
membrane.  Unless  the  wound  determines  the  site  of  the  skin  in- 
cision, it  should  be  a  longitudinal  one  made  in  the  median  line 
of  the  under  surface  of  the  penis.  After  operation  has  been  com- 
pleted, a  catheter  should  be  left  in  the  bladder  for  several  days. 
This  operation  may  be  easily  performed  with  the  aid  of  a  local 
anesthetic.  The  stitches  should  be  removed  in  five  days  or  a  week 
and  the  catheter  two  or  three  days  later.  In  most  instances  the 
deeper  parts  will  heal  with  scarcely  any  leakage  of  urine.  Should 
this  occur  the  sinus  will  in  a  few  days  close  of  itself,  since,  unlike 
the  condition  when  an  inflammatory  stricture  is  present,  the  tend- 
ency after  traumatism  is  toward  recovery.  All  silk  sutures  should 
be  so  placed  that  they  can  be  removed,  and  for  this  purpose  their 
ends  should  be  left  long;  otherwise  plain  catgut  should  be  em- 
ployed. If,  in  spite  of  all  precautions,  suppuration  occurs,  the 
catheter  must  be  taken  out  of  the  bladder  and  the  wound  freely 
drained.  After  the  inflammation  has  subsided,  a  second  operation 
may  be  undertaken  to  close  a  persisting  sinus.  If  the  sinus  is  a 
large  one  or  traumatic  stricture  exists,  a  section  of  the  urethra 


210      INFLAMMATIONS  OF  THE  MALE  GENITO-URINARY  ORGANS 

must  be  eu1  away  so  that  clean  fresh  ends  may  he  ohtained  for 
suture. 

Rupture  of  the  Bladder. — The  rupture  may  he  extraperi- 
toneal, hut  is  usually  intraperitoneal.  In  either  case  the  accident 
is  a  serious  one  and  follows  a  blow  or  fall,  usually  when  the  blad- 
der is  full.  When  it  is  overdistended  a  comparatively  slight  blow- 
may  rupture  it. 

Symptoms. — Rupture  of  the  bladder  has  some  symptoms  in 
common  with  rupture  of  the  urethra ;  but  it  may  be  differentiated 
by  the  history  of  the  accident,  by  pelvic  pain  and  shock,  by  the 
absence  of  visual  injury  in  the  perineum  or  along  the  penis,  by  the 
fact  that  blood  in  the  urine  is  thoroughly  mixed  with  it  and  does 
not  appear  simply  at  the  beginning  or  the  end  of  the  urinary 
act,  and  possibly  by  the  complete  absence  of  urine,  even  after  the 
passage  of  a  catheter.  Unless  stricture  is  present  there  will  be  no 
difficulty  in  passing  a  catheter  into  a  ruptured  bladder.  Extrava- 
sation of  urine  into  the  deeper  parts  of  the  pelvis,  or  its  discharge 
into  the  peritoneal  cavity,  will  also  cause  symptoms  which  will 
assist  in  the  diagnosis  of  the  injury. 

Treatment. — An  immediate  suprapubic  cystotomy  is  the  best 
form  of  treatment.  In  many  cases  this  must  be  combined  with  a 
laparotomy. 

Rupture  of  the  bladder  should  be  considered  a  possible  com- 
plication in  all  cases  of  fracture  of  the  pelvis. 

INFLAMMATIONS 

Burns. — Burns  of  the  external  genitals  may  be  of  the  usual 
kind,  or  they  may  be  due  to  the  application  of  too  strong  ointments 
or  lotions.  The  symptoms  and  treatment  are  those  of  burns  else- 
where in  the  body  (see  p.  26).  On  account  of  the  great  loose- 
ness of  the  skin  and  the  relative  firmness  of  the  deep  fascia  of 
these  parts,  the  edema  resulting  from  even  a  slight  burn  may 
produce  great  distortion  (Fig.  113).  Such  an  edema  is,  of  course, 
wholly  temporary,  and  the  patient  should  be  so  assured. 

Simple  Balanitis. — This  is  an  inflammation  of  the  mucous 
membrane  covering  the  head  of  the  penis,  and  the  inner  layer  of 
the  prepuce.  It  is  common  in  cases  of  long  prepuce,  especially 
if  the  foreskin  cannot  be  retracted.    Under  such  circumstances  the 


HERPES   OF  THE   PENIS 


211 


secretions  about  the  corona  remain  in  a  moist  condition  and  un- 
dergo fermentations.  Erosion  of  the  delicate  epithelial  layers 
results,  with  foul  smelling  discharge.  Diabetics  are  especially  sub- 
ject to  irritations  of  the  foreskin. 

Treatment. — Cleanliness,  the  application  of  a  powder,  such 
as  stearate  of  zinc,  or  the  application  of  a  bland  ointment  such  as 
cold  cream,  will  heal  the  simplest  cases.  The  apposed  surfaces 
may  be  kept  apart  by  a  wisp  of  cotton  moistened  with  a  dilute 
antiseptic.  If  the  foreskin 
cannot  be  retracted,  or  if 
it  is  very  long,  so  that  the 
head  of  the  (adult)  penis 
is  completely  covered,  cir- 
cumcision should  be  per- 
formed. The  resulting  ex- 
posure of  the  corona  will 
stimulate  the  growth  of  a 
tougher  epithelium,  and 
will  dry  the  secretions 
more  rapidly.  In  operat- 
ing upon  diabetics,  one 
should  remember  the  possi- 
bility of  a  failure  to  ob- 
tain primary  union. 

Herpes  of  the  Penis. 
— The  glans  penis  and  the      FlG-  113-—  Edema  of  the  Penis  and  Scr°- 

tum  in  Burn  due  to  the  Application  of 

inner  layer  of  the  prepuce  Mercueic  Ointment. 

may   break    out   with   the 

characteristic  groups  of  vesicles  by  which  herpes  is  known  in  all 
portions  of  the  body.  In  the  case  of  the  penis,  however,  the 
apposition  of  the  two  epithelial  layers  leads  to  the  speedy  macera- 
tion of  the  vesicles,  so  that  if  the  patient  is  not  promptly  seen, 
only  shallow  ulcers  may  be  found,  together  with  more  or  less  gen- 
eral inflammation. 

The  treatment  is  similar  to  that  advocated  for  balanitis.  The 
apposed  surfaces  should  be  kept  apart  by  a  wisp  of  cotton  or  a 
layer  of  gauze  moistened  with  some  mild  antiseptic,  such  as  a 
dilute  silver  solution,  or  a  drying  powder  may  be  employed,  or  a 
simple  ointment.  The  parts  should  be  frequently  cleansed  with 
16 


212      INFLAMMATION'S  OF  THE  MALE  GENITO-URINARY  ORGANS 


hot  saline  solution  to  prevent  irritation  from  accumulated  secre- 
tion. If  the  digestion  of  the  patient  is  faulty,  ii  should  be  cor- 
rected. 

Simple  Urethritis. — Inflammation  of  the  mucous  mem- 
brane of  the  urethra,  not  due  to  the  gonococcus,  may  follow  trau- 
matism, such  as  the  use  of  sounds,  or  excessive  or  unclean  coitus, 
or  the  ingestion  of  drugs  which,  passing  out  through  the  kidneys, 
may  irritate  the  urethra,  etc.  The  symptoms  are  those  of  catarrh 
of  mucous  membrane  everywhere — namely,  swelling,  tenderness, 
redness,  and  an  increase  in  the  mucous  secretion,  which  in  some 
cases  may  be  purulent.  Micro-organisms  may  be  found  in  the  dis- 
charge, but  they  will  not  be  gonococci.  The  lack  of  exposure  to 
gonococcus  infection,  the  absence  of  gonococci  from  the  discharge, 
and  the  quick  disappearance  of  symptoms,  serve  to  differentiate 
simple  urethritis  from  gonorrhea. 

Treatment. — With  the  removal  of  the  cause  of  irritation  and 
dilution  of  the  urine,  the  inflammation  quickly  subsides;  usually 
in  less  than  a  week.     The  patient  should  drink  as  many  as  four 

large  glasses  of  water, 
preferably  hot,  and 
taken  an  hour  before 
meals  and  at  bedtime. 
Sweet  spirits  of  niter, 
or  acetate  of  potash, 
or  some  other  di- 
uretic should  be  given 
to  reduce  the  acidity 
of  the  urine. 

Abscess.  — M  o  s  t 
of  the  infections  of 
the  external  genitals 
are  of  a  venereal 
character,  due  to  the 
organisms  of  gonor- 
rhea, chancroid,  or 
syphilis.  Cellulitis 
and  abscess  due  to  the 
~      ,     usual  pyogenic  organ- 

Fig.    114. — Abscess    of    Scrotum    of   Five    Days        _  rv    o  o 

Duration.     Patient  aged  twenty-five.  isms     do     OCCUr,     how- 


SPECIFIC  URETHRITIS,   OR  GONORRHEA  213 

ever,  both  in  the  penis  and  in  the  scrotum.  A  case  of  the  latter 
character  is  shown  in  Figure  114.  The  symptoms  and  treatment 
are  similar  to  those  of  abscess  in  other  parts  of  the  body. 

Specific  Urethritis,  or  Gonorrhea.— Gonorrhea  as  com- 
monly seen  is  an  acute  inflammation  of  the  anterior  urethra  due 
to  the  presence  of  a  specific  microbe  called  the  gonococcus.  Ac- 
cording to  the  best  authorities  it  can  be  obtained  only  by  contact 
with  a  person  who  has  recently  suffered  from  it,  or  with  some  of 
the  discharges  from  such  a  person.  In  most  cases  it  requires  from 
two  to  four  days  for  the  germ  to  develop  in  the  epithelium  after 
its  introduction  into  the  urethra.  After  this  interval  free  from 
symptoms,  there  is  noticed  an  itching  or  burning,  or  pain  greatly 
increased  during  micturition  and  during  an  erection,  and  a  puru- 
lent discharge.  The  mucous  membrane  swells,  and  often  pouts 
from  the  meatus.  The  inguinal  glands  swell  and  become  tender, 
but  rarely  suppurate.  These  symptoms  continue  for  two  or  three 
weeks  and  slowly  subside. 

Treatment. — The  varieties  of  treatment  advocated  for  this 
very  common  trouble  are  numerous  indeed.  None  of  them  is 
able  to  cut  short  to  any  great  extent  the  average  duration  of  the 
disease.  The  discharge  continues  usually  about  six  weeks.  It  is 
noticeable,  however,  that  in  succeeding  attacks  the  disease  pursues 
a  briefer  and  milder  course.  As  is  the  case  in  most  acute  inflam- 
mations, very  hot  water  is  grateful  to  the  patient,  who  should  soak 
his  penis  once  or  twice  a  day  in  a  large  tumbler  filled  with  water 
as  hot  as  he  is  able  to  bear  it,  with  the  idea  of  relieving  the  mucous 
membrane  from  the  irritation  of  its  own  discharges,  as  well  as  in 
the  hope  of  sterilizing  the  urethra  and  thus  cutting  short  the  attack. 
Many  specialists  upon  genito-urinary  diseases  have  advocated  the 
use  of  irrigation.  Tor  this  purpose  a  blunt  pointed  nozzle  is  pro- 
vided which  contains  two  openings  side  by  side.  With  each  of 
these  a  tube  is  connected,  one  coming  from  the  reservoir  of  irri- 
gating fluid,  the  other  leading  to  a  waste  pail.  The  nozzle  should 
distend  the  meatus  so  as  to  prevent  the  escape  of  fluid  around  it. 
Irrigation  may  be  carried  out  by  allowing  the  stream  to  flow  con- 
tinuously or  by  occasionally  stopping  the  outflow  in  order  slightly 
to  distend  the  penis  before  the  fluid  flows  out  of  it.  Mild  anti- 
septic solutions  can  be  used  for  this  purpose;  permanganate  of 
potash  in  water,  1  part  to  2,000,  is  one  of  the  favorites. 


214      INFLAMMATIONS  OF  THE  MALE  GENITO-URINARY  ORGANS 

It  has  been  claimed  that  injections  and  irrigations  have  a  tend- 
ency to  spread  the  gonorrhea  to  the  prostate,  bladder,  or  testicles, 
but  without  injections  of  any  sort  being  made  these  secondary  in- 
flammations often  develop,  so  that  an  injection  in  which  no  undue 
pressure  is  employed  probably  does  not  spread  the  disease  to  deeper 
parts.  Xature  has  provided  an  irrigation  for  the  urethra  in  the 
flow  of  urine  through  it  at  frequent  intervals,  so  that  the  irriga- 
tions above  described  are  not  as  necessary  as  they  otherwise 
would  be. 

The  urine  should  be  kept  bland  by  causing  the  patient  to  drink 
large  quantities  of  water,  milk,  weak  tea,  lemonade,  etc.  If  it  is 
desirable  to  reduce  acidity  still  further,  acetate  of  potash,  ten 
grains  every  four  hours,  or  some  other  diuretic  may  be  given. 

Tiest  is  another  essential  of  treatment.  The  patient  should  lie 
down  as  much  as  possible,  and  should  avoid  exercise,  tobacco,  alco- 
hol, and.  sexual  excitement  of  any  kind.  If  troubled  during  sleep 
with  erections  of  the  penis,  the  patient  should  take  during  the 
afternoon  and  evening  thirty  or  forty  grains  of  potassium  bromid. 
Constipation  should  be  prevented,  and  the  diet  should  be  a  simple 
one.  Such  are  the  general  principles  of  the  treatment  of  acute 
gonorrhea  upon  which  all  writers  agree. 

The  specific  treatment,  that  is,  treatment  which  has  in  view 
the  cure  of  the  disease  by  the  use  of  drugs,  is  by  some  writers 
asserted  to  be  useless ;  most  specialists,  however,  administer  drugs 
by  the  mouth  or  in  injections  into  the  urethra,  or  by  both  of  these 
methods.  The  drugs  given  internally  are  chiefly  copaiba,  cubebs, 
sandalwood  oil,  and  salol.  These  are  all  substances  which  are 
rapidly  excreted  by  the  kidneys,  and  give  to  the  urine  an  aromatic 
odor  and  a  certain  degree  of  disinfecting  power.  A  good  prescrip- 
tion is  as  follows : 

3   Salol,  )„ 

,_ ..  .  .    ,     >  aa gr.   iv  ; 

Oleoresm  cubeb,  ) 

Balsam  copaiba? gr.  viij  ; 

Pepsin    gi*.  j. 

One  or  two  capsules,  each  containing  the  above,  should  be  given 
after  each  meal. 

The  other  method  of  administering  drugs — namely,  that  of  in- 
jecting solutions  into  the  urethra — opens  a  wide  field  for  experi- 


SPECIFIC    URETHRITIS,   OR  GONORRHEA  215 

mentation.  Astringents  of  every  sort,  and  most  of  the  old  and 
new  disinfectants,  have  been  repeatedly  used  for  this  purpose. 
Their  efficacy  in  limiting  an  acute  gonorrhea  is  open  to  grave 
doubt,  though  the  astringent  solutions  are  of  undoubted  benefit 
in  the  later  stages  of  the  disease  when  the  purulent  secretion  has 
changed  to  a  thin  mucous  secretion.  The  following  solution  is 
often  employed: 

tf>   Argyrol 3iv ; 

Aquae   destil oviij. 

Sig. :  Use  locally  after  urination. 

Or  at  a  later  stage,  when  the  discharge  becomes  muco-purulent, 
the  following  mixture : 


I£   Zinc,  sulphat gr 


xv 


Plumbi  acetatis    gr.  xx; 

Tinct.  opii, 


.  aa oil : 

Tinct.  catechu,  ) 

Aquae   ad    ovj. 

M.  Sig. :  To  be  injected  after  urination. 

Complications. — The  prostate,  bladder,  and  testicle  may  all 
take  part  in  the  gonorrheal  inflammation.  It  requires  usually  two 
or  three  weeks  for  the  disease  to  spread  to  these  localities,  but 
when  it  has  done  so  the  same  symptoms  of  heavy  pain,  heat,  swell- 
ing, and  tenderness  to  touch  are  present  in  these  different  locali- 
ties, and  the  patient  has  the  constitutional  symptom  of  fever  of 
100°-102°  F.  If  the  bladder  is  affected,  micturition  is  frequent 
and  urgent,  extremely  painful,  and  is  often  followed  by  the  pas- 
sage of  small  quantities  of  blood.  Blood  may  also  be  mixed  with 
the  urine.  Inflammation  is  situated  in  the  neck  of  the  bladder 
as  well  as  in  the  prostate,  and  most  of  the  pain  is  referred  to  the 
base  of  the  penis  and  to  the  perineum.  Large  doses  of  alkaline 
diluents,  local  application  of  heat  in  the  form  of  hot  compresses, 
or  a  hot  sitz-bath  and  irrigation  of  the  rectum  with  hot  water,  or 
heat  applied  through  a  closed  rectal  tube,  will  all  relieve  the  pa- 
tient somewhat,  but  for  a  few  days  morphin  will  probably  be 
required,  and  may  be  administered  by  the  mouth  or  subcutane- 
ously  or  by  rectal  suppositories.  If  the  inflammation  does  not 
subside  in  a  few  days  the  bladder  should  be  irrigated  daily  through 


216      INFLAMMATIONS  OF  THE  MALE  OENITO  URINARY  ORGANS 

a  soft  rubber  catheter  with  ho1  saturated  solution  of  boric  acid, 
or  with  very  weak  solutions  of  nitrate  of  silver  (1:  4,000)  at  the 
beginning,  or  a  solution  of  protargo]  (1:  2,000). 

If  the  disease  extends  to  the  testicles  it  usually  attacks  only 
one  of  tlieni  at  a  time,  and  involves  chiefly  the  epididymis.  This 
swells  rapidly  until  it  is  several  times  the  normal  size,  and  is 
exquisitely  painful  and  tender.  Host  in  bed,  support  of  the  tes- 
ticle by  folded  towels  placed  upon  the  thighs,  and  the  application 
of  pounded  ice  or  hot,  moist  compresses  kept  hot  by  a  hot  water 
bottle,  will  suffice  to  relieve  the  pain  in  a  few  days.  Painting  the 
overlying  skin  with  a  mixture  of  equal  parts  of  guaiacol  and  olive 
oil  will  also  relieve  pain.  Often  the  swelling  persists  for  weeks, 
and  the  testicle  should  be  carried  in  a  suspensory  bandage  for  a 
long  time  after  the  patient  is  up.  Its  return  to  the  normal  size 
can  be  hastened  by  the  application  of  a  mixture  of  mercurial  and 
belladonna  ointment. 

Chronic  Gonorrhea :  Posterior  Urethritis. — By  the 
treatment  described,  or  even  without  treatment,  the  discharge 
in  acute  gonorrhea  usually  ceases  in  about  six  weeks.  Occasion- 
ally, however,  some  few  symptoms  of  the  disease  remain — a  little 
pain  after  urination,  an  occasional  drop  of  clear  mucus  sufficient 
to  keep  the  meatus  moist  and  to  disturb  the  mind  of  the  patient, 
or  a  few  shreds  in  the  urine.  The  disease  has  passed  into  a  chronic 
state  and  is  known  as  chronic  urethritis  or  gleet.  In  such  a  form 
it  resists  treatment  most  persistently.  This  is  due  sometimes  to 
irregularities  in  the  urethral  canal,  either  natural  or  the  result  of 
the  inflammation.  Behind  a  small  meatus  there  may  be  a  little 
pouch  in  which  the  inflammation  continues,  and  lights  up  from 
time  to  time  after  any  slight  irritation.  Or  there  may  be  a  stric- 
ture at  any  point  in  the  urethra  behind  which  the  inflammation 
keeps  up.  Such  a  stricture  is  due  to  the  contraction  of  scar  tissue, 
which  occurs  everywhere  in  the  body  where  healing  has  followed 
severe  inflammation  or  loss  of  tissue.  The  persistence  of  the  in- 
flammation may  also  be  due  to  the  fact  that  the  gonococci  have 
lodged  in  the  prostatic  ducts.  In  these  narrow  passages  they  are 
Avith  difficulty  reached  by  injections,  and  are  not  affected  by  the 
flow  of  urine. 

Treatment. — A  narrow  meatus  or  a  stricture  should  be  di- 
vided.    If  posterior  urethritis  exists  the  most  successful  treatment 


STRICTURE   OF   URETHRA  217 

is  the  injection  of  a  few  drops  of  a  strong  solution  of  nitrate  of 
silver  by  means  of  a  deep  urethral  syringe.  The  solution  first 
injected  may  have  a  strength  of  one  per  cent;  later,  if  necessary, 
stronger  solutions  may  be  employed.  The  instrument  should  be 
passed  into  the  membranous  urethra,  i.  e.,  about  six  inches  from 
the  meatus,  before  the  fluid  is  injected.  The  injections  should  be 
repeated  every  two  or  three  days.  The  effect  of  the  treatment  is 
heightened  if  the  prostatic  ducts  be  emptied  once  or  twice  a  week 
by  digital  pressure  applied  to  the  prostate  gland  through  the 
rectum. 

Stricture  of  Urethra. — This  is  a  cicatricial  narrowing  of 
the  canal,  usually  due  to  scar  formation  after  gonorrhea.  If  the 
caliber~>is  only  slightly  reduced,  the  symptoms  are  not  severe. 
There  i§  slight  discomfort  on  urination,  and  the  stream  is  irregular 
or  interrupted.  There  may  be  a  discharge  of  a  few  drops  of  clear 
mucus  at  times.  If  the  stricture  is  very  tight,  the  patient  is  con- 
stantly exposed  to  a  complete  obstruction  (see  Retention,  p.  219). 

Treatment. — The  aim  of  treatment  is  to  make  and  keep  the 
caliber  of  the  urethra  sufficiently  large,  and  also  uniform,  so  that 
pouches  may  be  done  away  with.  A  narrow  meatus  should  be  di- 
vided downward  by  a  blunt  pointed  knife,  after  a  little  cocain 
has  been  injected  hypodermically.  When  this  has  been  done  the 
urethra  should  be  carefully  examined  with  olive  tipped  bougies 
or  with  a  urethrometer.  These  instruments  should  be  sterilized 
and  lubricated  with  a  sterile  medium  such  as  boiled  olive  oil,  or  one 
of  the  manufactured  preparations  containing  sea-moss.  These  are 
soluble  in  water,  and  in  their  other  physical  properties  closely  re- 
semble mucus.  The  meatus  having  been  cleansed,  the  head  of  the 
penis  is  grasped  lightly,  and  a  small  bougie  is  passed  slowly  in- 
ward until  its  point  meets  an  obstruction  or  reaches  the  membra- 
nous portion  of  the  urethra.  If  no  obstruction  is  found,  larger 
and  larger  sizes  are  employed  until  the  limit  of  that  particular 
urethra  has  been  reached. 

If  a  stricture  is  present  it  may  be  dilated  gradually  or  imme- 
diately, or  it  may  be  divided  with  special  cutting  instruments. 
All  of  these  forms  of  treatment  have  often  been  carried  out  in  the 
surgeon's  office  or  in  the  dispensary,  but  sudden  dilatation  or 
divulsion,  as  it  is  called,  is  uncertain  and  is  not  now  in  vogue. 
Division  of  the  stricture  with  a  cutting  instrument  (internal  ure- 


218      INFLAMMATIONS  OF  THE  MALE  GENITO-URINARY  OKUANS 

throtomy)  is  not  without  danger.  There  is  some  risk  of  hemor- 
rhage. Inn  this  is  usually  controlled  without  difficulty.  A  greater 
risk  is  due  to  the  severe  nervous  symptoms  which  sometimes  fol- 
low even  a  slight  insult  to  the  urethra. 

The  choice  between  gradual  dilatation  and  division  of  a  stric- 
ture depends  somewhat  upon  the  condition  of  the  patient  aud  his 
circumstances,  as  well  as  upon  the  character  of  the  stricture.  If 
the  latter  is  elastic,  of  not  too  small  caliber,  and  gives  only  mod- 
erate symptoms,  most  surgeons  are  content  with  gradual  dilata- 
tion. This  should  be  carried  on  under  strict  aseptic  precautions, 
steel  sounds  (Fig.  115)  being  passed  every  two  or  three  days  if 


Fig.  115. — A  Good  Type  of  Steel  Sound.     The  shaft  is  smaller  than  the  shoulder 
and  does  not  therefore  drag  the  meatus.     It  should  be  held  as  lightly  as  a  pencil. 

the  urethra  does  not  react  too  violently.  Later  when  a  full  sized 
sound  is  easily  passed,  the  treatment  may  be  performed  only  once 
in  a  week  or  two.  The  sound  should  be  held  as  lightly  as  a  pencil 
between  the  tips  of  the  thumb  and  fingers. 

If  the  passage  of  the  sound  is  too  painful,  a  few  drops  of  a 
one  per  cent  solution  of  cocain  may  be  injected  into  the  urethra. 
A  strong  solution  of  cocain  should  never  be  used  for  this  purpose, 
as  death  from  absorption  has  more  than  once  occurred.  On  each 
occasion  two  or  three  sounds,  each  one  a  little  larger  than  the 
preceding  one,  may  be  passed;  but  it  is  well  to  begin  each  time 
with  a  sound  one  or  two  numbers  smaller  (French  scale)  than  the 
largest  one  passed  at  the  previous  treatment.  This  gives  the  pa- 
tient confidence  at  the  start,  and  reminds  the  surgeon  of  the  par- 
ticular curves  of  the  patient's  urethra.  The  permanent  cure  of  a 
stricture  is  often  a  matter  of  several  months. 

Internal  urethrotomy  is  not  properly  a  minor  surgical  opera- 


RETENTION    OF    URINE  219 

tion,  and  need  not  be  considered  in  detail.  Suffice  it  to  say  that 
after  the  stricture  is  cut  tfye  caliber  of  the  urethra  should  be  at 
once  tested  by  the  passage  of  a  full  sized  sound.  This  should 
be  repeated  again  in  four  or  five  days,  and  every  few  days  there- 
after for  a  month  or  so. 

Retention  of  Urine. — If  a  stricture  of  the  urethra  is  very 
tight,  admitting  only  the  smallest  instruments  (No.  6  French  or 
less),  the  symptoms  mentioned  above  are  more  pronounced  and 
at  any  time  an  acute  swelling  of  the  mucous  membrane  about  the 
stricture  may  shut  off  the  passage  entirely.  When  this  occurs, 
there  is  a  complete  retention  of  urine,  one  of  the  most  painful  con- 
ditions which  can  possibly  be  experienced.  Sometimes  the  strain- 
ing bladder  may  force  a  little  urine  past  the  stricture,  but  without 
much  relief  of  the  symptoms  of  retention.  There  will  then  be  a 
constant  dribbling  sufficient  to  keep  the  patient  alive,  but  not  to 
relieve  him  of  his  agony.  This  condition  of  affairs  requires  imme- 
diate treatment. 

Although  stricture  is  the  commonest  cause  of  retention  of 
urine,  it  is  well  to  bear  in  mind  that  it  may  be  due  to  a  number 
of  other  causes,  such  as  enlargement  of  the  prostate  gland,  a  con- 
dition nbt  usually  found  before  middle  life ;  or  a  stone  in  the  blad- 
der; or  injury  to  the  deep  urethra  or  the  bladder;  or  a  tumor;  or 
it  may  follow  exposure  to  cold  in  persons  of  delicate  constitution ; 
or  accompany  lesions  of  the  spinal  cord.  The  history  of  the  pa- 
tient, together  with  the  facts  elicited  by  examination,  should 
enable  the  surgeon  to  make  a  correct  diagnosis  in  most  cases.  The 
necessity  for  immediate  relief  is  equally  great,  whatever  the  cause 
of  the  retention. 

Treatment. — The  simplest  measures  should  first  be  tried. 
Sometimes,  to  the  great  relief  of  patient  and  surgeon,  a  medium 
sized  soft  rubber  catheter,  if  well  lubricated  and  steadily  pressed 
against  the  obstruction,  will  after  a  few  minutes  pass  the  stricture 
and  bring  the  desired  relief.  When  the  bladder  has  been  emptied, 
or  partially  emptied  if  its  distention  has  been  very  great,  and  the 
patient  has  been  put  to  bed  on  a  light  diet  and  his  bowels  moved, 
the  power  to  empty  the  bladder  voluntarily  often  returns;  but 
should  subsequent  catheterization  be  necessary,  it  is  usually  easily 
performed.  When  acute  symptoms  have  passed  over,  the  stric- 
ture should  be  appropriately  treated. 


221)      INFLAMMATIONS  OF  THE  MALE  GENITO-URINARY  ORGANS 

If  a  soft  catheter  cannot  be  passed,  success  may  follow  the  use 
of  a  silver  instrument,  although  more  often  the  point  is  pushed 
through  the  mucous  membrane  and  burrows  outside  of  the  urethra 
without  reaching  the  bladder. 

The  bladder  itself  may  be  aspirated  by  means  of  a  fine  trocar 
and  cannula  inserted  just  above  the  pubes.  As  the  greatly  dis- 
tended bladder  has  lifted  the  peritoneal  reduplication,  there  is 
no  danger  that  the  instrument  will  enter  the  peritoneal  cavity. 
When  the  bladder  has  been  thoroughly  emptied,  catheterization  or 
normal  urination  may  become  possible. 

In  more  severe  cases  of  retention  three  methods  of  radical  re- 
lief are  available:  namely,  suprapubic  cystotomy,  internal  ure- 
throtomy, and  external  urethrotomy.  The  objection  to  the  first, 
if  the  retention  is  due  to  stricture,  is  that  it  does  not  relieve  the 
cause  of  the  retention.  The  second  is  only  possible  in  case  a  fili- 
form bougie  can  be  passed  into  the  bladder.  If  this  can  be  done, 
usually  enough  urine  will  escape  around  it  to  relieve  very  mate- 
rially the  patient's  condition,  and  after  a  few  hours  the  stricture 
will  dilate  sufficiently  to  allow  the  passage  alongside  of  the  fili- 
form of  the  guide  to  Maisonneuve's  instrument  for  internal  ure- 
throtomy, or  with  the  filiform  alone  in  position  an  external  ure- 
throtomy may  be  performed.  This  is  a  comparatively  easy  oper- 
ation under  the  circumstances.  If,  however,  no  guide  can  be 
passed  into  the  bladder,  the  external  urethrotomy  may  be  ex- 
tremely difficult,  since  the  finding  of  the  urethra  beyond  the 
stricture  may  tax  the  surgeon's  ability  to  the  utmost.  The  details 
of  these  operations  are  found  in  all  good  surgical  text-books. 

Incontinence  of  Urine. — Dribbling  of  urine  from  an  over- 
full bladder  is  really  a  symptom  of  retention,  although  it  is  gen- 
erally spoken  of  as  incontinence.  True  incontinence,  or  the  in- 
ability of  the  bladder  to  retain  the  usual  amount  of  urine,  may 
be  due  to  disease  of  the  bladder  itself  or  to  some  alteration  in  its 
nervous  control.  An  example  of  the  latter  is  the  incontinence  of 
childhood. 

Incontinence  of  Childhood. — This  is  seen  in  both  sexes,  and 
may  be  diurnal  or  nocturnal,  though  the  latter  is  more  common. 
It  is  a  continuation  of  an  infantile  condition,  but  parents  do  not 
usually  pay  much  attention  to  it  until  the  child  is  five  or  six  years 
old.     It  varies  greatly  in  degree,  some  children  wetting  the  bed 


INCONTINENCE   OF   URINE  221 

every  night  or  twice  a  night,  others  being  affected  occasionally. 
The  children  who  are  affected  in  the  daytime  are  seized  with  a 
desire  to  urinate  and  cannot  retain  the  urine  long  enough  to  get 
to  a  closet. 

Treatment. — The  urine  should  be  examined,  the  daily  quan- 
tity determined,  and  the  maximum  capacity  of  the  bladder  ascer- 
tained. Acid  urine  should  be  rendered  bland.  The  possibility 
of  vesical  calculus  should  not  be  overlooked. 

The  general  health  and  habits  should  be  attended  to.  One  little 
girl  showed  marked  improvement  as  soon  as  she  gave  up  jump- 
ing rope. 

The  intelligent  cooperation  of  the  child  should  be  obtained. 
Usually  the  child  has  been  scolded  and  punished  until  it  is  filled 
with  fright  and  shame  at  the  mere  thought  of  urination.  This  is, 
of  course,  an  unfavorable  attitude  of  mind  and  should  be  changed 
as  quickly  as  possible.  To  give  the  child  a  correct  view  of  the 
functions  of  its  bladder  and  of  the  possibility  of  strengthening 
them  by  exercise  and  by  voluntary  retention  of  urine  after  the 
desire  is  first  noticed,  will  at  once  gain  its  sympathy  and  assist- 
ance. The  amount  of  urine  passed  at  one  time  and  the  length  of 
intervals  between  urination  should  be  graphically  shown  by  a  meas- 
uring glass  and  a  record. 

The  patient  should  not  drink  freely  in  the  evening  and  should 
retire  with  an  empty  rectum  as  well  as  bladder.  The  clothing 
should  be  light.  Constipation  should  be  relieved.  A  long  fore- 
skin should  be  removed  by  circumcision.  In  every  case,  male  or 
female,  a  careful  physical  examination  should  be  made.  Some- 
times seat  worms  are  an  exciting  cause. 

Belladonna,  quinin,  and  some  other  drugs  may  be  tried.  Many 
cures  have  been  reported  following  their  use. 

In  obstinate  cases  a  small  steel  urethral  sound  should  be  passed 
twice  a  week. 

There  is  always  a  tendency  toward  recovery  with  the  growth 
of  the  child. 

Incontinence  of  Old  Age. — This  is  chiefly  found  in  women  who 
have  borne  children  and  who  have  a  laxity  of  the  perineum  and 
of  the  vaginal  walls.  Combined  with  this  decrease  in  mechanical 
support  of  the  bladder  there  is  also  a  decrease  in  muscular  power 
of  the  sphincter.     The  result  is  the  inability  to  retain  more  than 


222      INFLAMMATIONS  OF  THE  MALE  GENITO-URINARY  ORGANS 

a  few  ounces  of  urine,  so  that  it  escapes  upon  coughing  or  motions 
which  increase  the  intra-abdominal  pressure.  In  other  cases  a 
urethral  polyp  or  caruncle  may  be  at  fault. 

Relief  is  to  be  looked  for  in  operations  which  restore  the  in- 
tegrity of.  the  pelvic  floor.  Sometimes  a  pessary,  by  preventing 
displacement  or  prolapse  of  the  uterus,  will  render  good  service. 
Abnormally  acid  or  alkaline  urine  should  be  brought  to  a  normal 
reaction.  Urethral  polyp  or  caruncle  should  be  removed  by  opera- 
tion (see  p.  270). 

Catheterization. — A  few  w7ords  upon  the  best  way  to  per- 
form this  simple  act  may  not  be  out  of  place  in  this  connection. 
It  is  practically  impossible  to  sterilize  the  meatus  and  urethra,  so 
that  patients  whose  condition  requires  catheterization  for  months 
or  years  usually  succumb  to  infection  of  the  bladder  and  kidneys. 
Nevertheless,  the  advantages  of  cleanliness  are  here  very  marked. 
Rubber  catheters  should  be  boiled  or  scalded  with  boiling  water 
after  being  used,  and  kept  in  weak  antiseptic  solutions  until 
wanted.  They  should  then  be  rinsed  with  boiled  water  and  lubri- 
cated with  a  sterile  medium.  The  meatus  of  the  patient,  as  well 
as  the  hands  of  the  catheterizer,  should  be  carefully  disinfected. 
In  fact,  it  is  better  to  use  rubber  gloves,  which  can  be  readily  dis- 
infected by  boiling.  As  gloves  for  this  purpose  need  not  be  very 
thin,  they  wall  last  a  good  while.  As  soon  as  a  rubber  catheter 
loses  its  smooth  surface  it  should  be  replaced  by  a  new  one. 

When  one  calls  to  mind  the  fact  that  men  have  catheterized 
themselves  for  years,  carrying  a  rubber  catheter  around  in  the 
vest  pocket,  and  perhaps  never  washing  it,  and  have  still  escaped 
infection,  such  precautions  as  have  been  above  described  may  seem 
unnecessary.  They  are  not  so,  however,  and  while  some  persons 
possess  great  power  of  resistance  to  disease  germs,  others  fall  an 
easy  prey,  and  should  be  protected  as  far  as  possible. 

Eczema. — The  external  genitals,  both  penis  and  scrotum,  are 
favorite  sites  for  eczema  (Fig.  116).  This  condition  is  often  due 
to  or  aggravated  by  uncleanliness  or  the  larger  or  smaller  parasites 
(scabies). 

Chancroid. — A  chancroid  is  a  small  ulcer  appearing  on  the 
head  of  the  penis,  or  foreskin,  or  possibly  on  the  skin  of  the  penis 
or  scrotum,  or  even  of  the  thigh.  It  is  due  to  infection  by  direct 
contact  with   a   virulent  venereal   discharge.      Presumablv  some 


CHANCROID  223 

slight  break  in  the  skin  allows  the  poison  to  gain  a  foothold.  Such 
a  lesion  makes  its  appearance  within  a  day  or  two  after  inocula- 
tion. It  usually  grows  larger  for  several  days,  and.  may  encircle 
the  penis  and  eat  away  a  considerable  portion  of  its  substance; 
but  such  rapid  destruction  is  uncommon  and  the  typical  ulcer  has 
the  diameter  of  a  quarter  or  half  an  inch.  There  may  be  more 
than  one  ulcer,  either  because  the  skin  has  been  inoculated  in  more 


Fig.  116. — Eczema  of  the  Penis  of  Four  Months'  Duration. 

than  one  spot  or  because  of  autoinoculation  from  point  to  point. 
This  explains  the  occurrence  of  ulcers  upon  the  scrotum  or  thighs. 
The  ulcers  are  usually  shallow,  not  extending  below  the  cutaneous 
layer.  There  is  a  certain  amount  of  surrounding  inflammation, 
and  often  lymphangitis  and  lymphadenitis;  the  vessels  leading 
to  one  or  both  groins  carrying  the  infection  into  the  inguinal 
glands  (inguinal  adenitis  or  bubo).  The  lesions  in  both  skin 
and  glands  are  painful,  and  there  is  the  constitutional  disturbance 


224       INFLAMMATIONS  OF  THE  MALE  GENITO-URINARY  ORGANS 

always  scon  in  the  presence  of  acute  infection.  The  primary 
sore,  unless  -nine  caustic  has  been  applied  to  it,  lacks  the  sur- 
rounding induration  of  a  primary  syphilitic  lesion.  If  the  chan- 
croidal ulcer  has  been  cauterized  a  differential  diagnosis  is  more 

difficult. 

Treatment. — A  chancroid  is  best  treated  by  a  local  hot  bath 
two  or  three  times  daily,  followed  by  careful  cleansing-  with  an 
antiseptic  solution,  such  as  peroxid  of  hydrogen  diluted  with  four 
parts  of  water.  Absorbent  cotton,  wet  with  a  solution  of  zinc  sul- 
phate 1  to  60,  or  some  other  lotion,  may  either  be  held  in  place  by 
drawing  the  foreskin  over  it  or  by  a  bandage.  In  the  latter  case 
the  dressing  should  be  moistened,  without  removing  it,  every  hour 
or  two  to  facilitate  discharge.  Surrounding  skin  should  be  pro- 
tected against  contamination  and  the  patient  advised  of  the  high 
degree  of  infectiousness  of  the  discharge.  By  this  treatment  pain 
will  be  much  relieved,  the  ulcer  will  soon  take  on  a  healthy  appear- 
ance and  will  heal  in  two  or  more  weeks,  according  to  its  size  and 
the  condition  of  the  patient.  The  use  of  strong  caustics  is  never 
advisable.  Excision  of  the  lesion  and  suture  of  the  wound  often 
fails  to  give  primary  union. 

Treatment  of  Bubo. — The  inguinal  glands,  if  moderately 
inflamed,  may  be  treated  by  counter-irritants ;  e.  g.,  equal  parts  of 
belladonna  ointment  and  an  ointment  containing  ichthyol  oj  to 
vaseline  oj-  This  is  more  likely  to  succeed  in  glands  swollen  from 
non-venereal  causes.  If  pain  and  swelling  are  severe  the  patient 
should  go  to  bed  and  apply  an  ice-bag  or  hot  moist  compresses  to  the 
groin.  If  the  glands  suppurate,  as  they  usually  do,  the  individual 
abscesses  may  be  opened  or  the  glands  entirely  dissected  away.  If 
the  abscesses  are  simply  incised  and  drained,  the  patient  will  re- 
quire to  be  dressed  for  several  weeks,  but  he  will  be  able  to  go  about 
without  much  discomfort.  Complete  removal  of  the  glands  seems 
a  formidable  procedure,  but  in  about  one-half  of  the  patients  so 
operated  upon  primary  union  of  the  parts  may  be  obtained.  This 
enables  the  patient  to  go  home,  entirely  well,  after  ten  days  or  two 
weeks  of  hospital  treatment.  If  primary  union  is  not  obtained, 
the  time  of  healing  is  probably  no  longer  than  would  have  been  the 
case  had  a  simple  incision  been  made.  According  to  the  writer's 
experience,  primary  union  may  be  reasonably  expected  if  the  skin 
overlying  the  glands  is  not  affected.     If,  however,  there  are  minute 


SYPHILIS 


225 


abscesses  in  the  roots  of  the  pubic  hairs,  primary  union  need  not 
be  hoped  for. 

Syphilis. — A  chancre  is  the  primary  lesion  of  syphilis  and 
may  occur  anywhere  upon  the  surface  of  the  body.  Since  it  is 
contracted  by  direct  contact  with  another  individual  suffering  from 
syphilis  in  an  acute  stage,  the  primary  lesion  in  the  male  is  usu- 
ally found  at  the  meatus  or  upon  the  head  of  the  penis  or  in  the 
more  delicate  part  of  the  foreskin  just  behind  the  corona;  but  it 
may  also  arise  in  the  tougher  skin  of  the  penile  body  (Fig.  117). 
It  is  noticed,  in  most  cases,  ten  days  or  two  weeks  after  infec- 
tion. In  some  cases  an  in- 
terval of  four  weeks  or  more 
elapses.  The  lesion  is  then 
a  small  indurated  nodule  in 
the  skin,  with  only  a  slight 
loss  of  epithelial  covering. 
The  ulcer  increases  some- 
what in  size  in  the  ensuing 
weeks,  but  if  uncomplicated 
it  never  grows  very  large  and 
is  not  very  painful.  It  heals 
slowly  and  the  induration 
lasts  for  many  weeks  after 
the  ulcer  has  completely  cica- 
trized. This  is  one  of  the 
chief  points  in  the  differen- 
tial diagnosis  between  a  chan- 
croid and  a  chancre.  The  in- 
guinal glands  are  usually 
somewhat  enlarged,  but  they 
are  not  as  tender  as  they  are  in  connection  with  a  chancroid,  nor 
do  they  suppurate. 

Treatment. — An  uncomplicated  chancre  needs  little  treat- 
ment; it  may  be  dusted  with  calomel  or  covered  with  mercurial 
ointment  or  some  simple  ointment.  Constitutional  treatment  is 
required  to  cure  the  disease,  and,  for  obvious  reasons,  such  treat- 
ment ought  to  be  withheld  until  such  diagnosis  is  absolutely  cer- 
tain, that  is,  until  the  micro-organism  has  been  demonstrated  in 
the  serum  from  the  lesion  (spirocheta  pallida)  or  secondary  mani- 


Fig.  117. — Primary  Lesions  of  Syphilis 
in  a  Patient  Aged  Seventy-four 
Years.  Diagnosis  made  from  micro- 
scopical examination  confirmed  by  sub- 
sequently obtained  history. 


220      INFLAMMATIONS  OF  THE  MALE  CEN1TO-URINARY  ORGANS 

festations  of  syphilis  have  appeared.  Resection  of  the  chancre  lias 
been  practised  in  the  hope  of  preventing  the  syphilitic  infection 
from  saining  access  to  the  bodv ;   but  such  treatment  docs  not 

DO  *      7 

achieve  this  result  for  the  obvious  reason  that  the  syphilitic  virus 
has  plenty  of  time  to  be  absorbed  before  the  surgeon  has  an  oppor- 
tunity to  remove  the  primary  sore.  The  constitutional  treatment 
is  all-important  (see  p.  61). 

Mixed  Infection. — A  chancroid  and  chancre  may  be  combined, 
that  is,  both  sorts  of  infection  may  enter  the  body  at  the  same 
point.  In  this  case  the  lesion  will  present  the  hardness  of  the 
chancre  and  the  acute  virulence  of  the  chancroid,  and  the  inguinal 
glands  may  or  may  not  suppurate.  An  ulcer  of  this  mixed  char- 
acter is  much  more  difficult  to  heal  than  a  simple  chancroid,  and 
it  may  eat  away  a  considerable  portion  of  the  head  of  the  penis 
before  its  processes  can  be  stopped.  A  patient  in  this  condition 
requires  all  the  help  which  can  be  obtained  from  the  best  hygienic 
surroundings  and  food.  The  local  treatment  is  substantially  that 
indicated  for  a  chancroid.  The  healing  process  is  slow,  and  it  may 
be  advisable  to  change  from  one  kind  of  dressing  to  another,  as 
the  stimulating  effect  of  any  one  application  grows  less  with  its 
continued  use.  These  mixed  infections  are  often  puzzles  in  diag- 
nosis until  secondary  syphilitic  lesions  appear.  Previous  to  that 
time  it  may  be  impossible  to  say  whether  the  induration  is  due 
to  the  virulence  of  the  infection  or  to  the  coexistence  of  syphilis. 
If  the  spirochete  can  be  demonstrated  in  the  discharge  the  ques- 
tion is  at  once  settled. 

Secondary  Lesions :  Mucous  Patches. — The  usual  papular  lesions 
may  appear  on  the  penis  and  scrotum.  If  they  are  so  situated  as 
to  be  kept  constantly  moist  by  the  apposition  of  cutaneous  surfaces 
they  may  take  on  the  characteristics  of  a  mucous  patch  with  a  sur- 
face covered  with  a  grayish,  foul  membrane,  and  possibly  with 
hypertrophy  of  the  base,  giving  a  papillary  form  to  the  growth. 
Such  lesions  are  much  commoner  upon  the  female  genitals  and 
about  the  anus.     (See  Fig.  131,  p.  268,  and  Fig.  140,  p.  300.) 

Syphilitic  Orchitis. — One  form  of  late  syphilitic  lesion  is  the 
involvement  of  one  or  both  testicles — syphilitic  orchitis  (Fig.  118). 
This  may  take  place  a  few  months  after  the  primary  lesion,  or  at 
any  time  afterward  up  to  many  years.  The  only  early  subjective 
symptom  is  a  feeling  of  weight  or  dull  pain  in  the  slowly  enlarg- 


SYPHILIS  227 


ing  testicle.  This  when  examined  is  found  to  be  uniformly  indu- 
rated and  enlarged.  The  enlargement  involves  chiefly  the  orchis, 
and  the  relatively  small  epididymis  can  usually  be  felt  as  a  flat 
appendage  at  the  rear.      This  is  the  common  type  of  syphilitic 


Fig.  118. — Unilateral  Syphilitic  Orchitis.     Duration,  six  weeks.     Patient  aged 

sixty-eight  years. 

orchitis,  though  occasionally  the  process  is  much  more  acute,  and 
therefore  painful ;  or  distinct  gummata  may  be  noticeable  from 
the  beginning,  giving  the  swelling  a  nodular  character  and  prob- 
ably leading  to  involvement  of  the  skin  and  slough  (Fig.  119). 
Similar  gumma  and  ulceration  may  occur  in  the  penis. 

Syphilitic  orchitis  is  a  very  slow  process,  both  in  its  develop- 
ment and  in  its  disappearance.  It  has  one  of  three  outcomes.  It 
may  entirely  resolve,  leaving  the  testicle  as  before.  It  may  lead 
to  atrophy  of  the  testicle.     It  may  ulcerate,  and  ultimately  heal 

with  more  or  less  loss  of  testicular  tissue  and  resulting  scar  for- 
17 


228      INFLAMMATIONS  OF  THE  MALE  (lEMTo   I  Til. VARY  ORGANS 

mation.  In  this  third  form  it  is  difficult  to  distinguish  it  from 
tuberculosis. 

In  the  early  stage  of  these  two  diseases  the  difference  in  loca- 
tion can  usually  be  made  out,  syphilis  affecting  the  orchis  and 
tuberculosis  beginning  in  the  epididymis.  In  the  later  ulcerating 
stage  this  distinction  may  be  impossible,  because  the  swelling  has 
so  altered  normal  relations  and  because  of  the  extension  of  the 
inflammation  beyond  its  original  site. 

Another  distinguishing  mark  of  tuberculosis  is  the  presence  in 
most  cases  of  several  hard  nodules  due  to  separate  foci  of  infec- 
tion. Such  are  wanting  in  syphilis.  If  the  tubercular  nodules 
exist   also   in  the  vas   deferens,   the   diagnosis   is   at   once   clear. 


Fig.  119. — Syphilis  of  Testicle.     Duration  eight  weeks.     Ulceration   through  the 
skin  of  four  days'  duration:  patient  aged  twenty-eight  years. 


Tuberculosis  breaks  down  more  promptly  than  a  gumma,  dis- 
charges more  pus,  tends  to  form  flabby  granulations,  and  has  less 
wide-spread  induration  about  a  single  center  of  infection. 

Syphilis  of  the  testicle  must  also  be  differentiated  from  malig- 
nant disease — either  carcinoma  or  sarcoma.  A  malignant  growth 
increases  rapidly  in  size,  is  softer,  produces  great  dilation  of  the 
blood-vessels,  superficial  and  otherwise,  involves  the  skin  of  the 
scrotum,  and  often  breaks  down,  forming  a  gangrenous  ulcer. 


TUBERCULOSIS  229 

Treatment. — The  patient  should  wear  ;i  suspensory  bandage. 
Belladonna  ointment  may  be  applied  over  the  swollen  testicle. 
The  only  curative  treatment  is  constitutional,  and.  consists  in  the 
administration  of  iodid  of  potash,  either  alone  or  in  combination 
with  a  mercurial. 

Tuberculosis. — Tuberculosis  of  the  genito-urinary  system 
usually  begins  in  the  testicles  in  the  male,  although  the  kidneys, 
one  or  both,  or  rarely  the  bladder,  may  first  show  signs  of  the 
disease.  Tubercular  cystitis  is  one  of  the  worst  forms  of  disease 
a  physician  is  called  upon  to  treat. 

Tuberculosis  in  the  testicle  sometimes  follows  a  slight  injury 
and  sometimes  develops  spontaneously.  Its  early  progress  may  be 
unnoticed,  or  there  may  be  a  moderate  acute  swelling,  chiefly  of 
the  epididymis,  which  causes  the  patient  a  little  pain.  In  either 
case  the  characteristic  lesions  soon  appear.  On  palpation  there 
will  be  found  one  or  more  moderately  tender  indurated  foci  in  the 
epididymis.  These  are  the  tubercular  nodules.  As  the  disease 
progresses  other  nodules  may  appear  either  in  the  epididymis  or 
in  the  cord,  or  in  the  corresponding  seminal  vesicle,  as  detected 
by  the  finger  in  the  rectum.  Possibly  no  nodule  may  be  felt  in 
the  cord  or  seminal  vesicle,  these  structures  simply  being  harder 
and  larger  than  those  of  the  opposite  side.  The  testicle  itself 
increases  in  size,  owing  to  the  inflammatory  products  around  the 
tubercular  nodule.  Still  later  the  centers  of  one  or  more  nodules 
may  break  down  and  resulting  purulent  and  necrotic  fluid  may 
work  its  way  to  the  surface  and  be  discharged.  A  permanent 
sinus  will  result,  discharging  the  watery,  flaky,  seropurulent  fluid 
characteristic  of  tubercular  sinuses. 

Usually  the  disease  is  unilateral,  although  it  sometimes  hap- 
pens that  both  seminal  vesicles  will  be  affected,  while  only  one 
testicle  shows  signs  of  disease.  In  the  beginning  of  the  trouble 
the  patient's  health  may  be  good.  Later,  a  careful  examination 
will  usually  show  some  evidence  of  tuberculosis  in  the  lungs  or 
elsewhere.  The  differential  diagnosis  of  syphilis  of  the  testicle  is 
given  above. 

Treatment. — The  appropriate  treatment  is  an  early  and  com- 
plete removal  of  so  much  of  the  diseased  tissue  as  is  accessible. 
If  a  single  movable  node  exists  it  may  be  allowable  to  excise  it 
without  removing  the  whole  testicle.    Usually,  however,  unilateral 


230      INFLAMMATIONS  OF  THE  MALE  GENITO-URINARY  ORGANS 

castration  should  be  performed  and  as  much  of  the  vas  deferens  as 
possible  should  be  pulled  out  with  it.  Xo  dangerous  hemorrhage 
follows  this  so-called  evulsion  of  the  vas.  To  remove  affected 
seminal  vesicles  through  a  perineal  incision  is  a  serious  operation. 
Simple  castration  is  described  on  page  235.  When  performed 
for  tuberculosis  of  the  testicle,  it  has  to  be  slightly  modified  on 
account  of  the  involvement  of  the  scrotum,  and  the  necessity  of 
removing  as  much  of  the  vas  deferens  as  possible.  The  incision 
should  be  made  in  the  direction  of  the  cord,  and  should  extend 
nearly  as  high  up  as  the  external  ring.  At  its  lower  end  it  should 
circle  around  the  involved  skin,  being  carried  wide  of  any  sinus, 
as  there  will  be  plenty  of  surplus  skin  after  the  testicle  has  been 
removed.  When  the  testicle  with  its  attached  diseased  skin  has 
been  separated  from  the  scrotum,  the  cord  should  be  freed  by  blunt 
dissection  up  to  the  external  ring.  The  vas  should  be  isolated, 
and  all  of  the  other  structures  of  the  cord  cut  squarely  across. 
Divided  vessels  should  be  separately  ligated  and  an  additional 
ligature  placed  around  the  stump  of  the  cord.  The  testicle  is 
now  connected  to  the  body  only  by  the  vas  deferens.  Steady  trac- 
tion is  made  upon  this.  The  grasp  of  the  fingers  is  more  firm 
if  the  vas  is  wrapped  in  gauze.  As  more  and  more  of  the  vas 
appears  at  the  external  ring,  the  vas  should  be  grasped  higher  up 
so  that  if  it  breaks  the  greatest  possible  length  may  be  secured.  In 
this  manner  from  six  to  twelve  inches  may  be  pulled  out.  The 
wound  in  the  scrotum  is  sutured  with  fine  silk  or  catgut.  The 
irregular  incision  often  makes  necessary  a  Y-shaped  suture  line. 
Most  of  the  blood  supply  of  the  scrotum  reaches  it  through  the 
median  raphe,  so  that  particular  attention  should  be  given  to  this 
part  if  the  excision  extends  to  the  opposite  side.  If  there  is 
oozing,  a  slight  drain  should  be  used.  Hidden  hemorrhage  after 
scrotal  excision  is  very  common,  and  may  require  reopening  the 
wound  and  ligation.  Hence,  it  is  well  to  avoid  this  by  a  careful 
ligation  of  all  vessels.  One  cannot  trust  to  pressure  of  the  dress- 
ing in  this  location,  as  it  is  safe  to  do  after  many  other  wounds. 


CIIAPTEK    IX 

TUMORS  AND    DEFORMITIES  OF  THE  MALE  GENITO- 
URINARY ORGANS 

CYSTIC   TUMORS   OF   THE   EXTERNAL   GENITALS 

Cysts  of  the  Skin. — A  retention  cyst  containing  serum  or 
sebaceous  material  may  be  found  in  the  skin  of  the  penis  (Fig. 
120)  or  scrotum. 

Sebaceous  material  retained   back  of  the  corona   in   children 


Fig.   120. — Serous  Gyst  of  the  Prepuce.     This  occurred  in  a  patient  aged  fifty-five 
years,  who  had  a  large  left  inguinal  hernia. 

with  long,  narrow  foreskins  frequently  becomes  encysted.      The 
overlying  epithelium  in  these  cases  is  thin,  and  can  be  wiped  away 

231 


232        TUMORS   OF   THE   MALE   GENITO-UR1NARY   ORGANS 


with  gauze  as  soon  as  the  foreskin  is  fully  retracted.     Deeper  col- 
lections of  epithelial  cells  and  sebaceous  material  may  also  form 
in  this  region  (Fig.  121),  possibly  on  account  of  inexact  approxi- 
mation of  the  edges  of  epithelium 
after  circumcision. 

The  scrotum  is  also  a  common 
scat  of  milia  (see  p.  60). 

Treatment. — Smaller  cysts 
may  be  evacuated  and  their  cavi- 
ties allowed  to  granulate;  but  a 
better  plan  for  them  and  for 
larger  cysts  is  the  removal  of  the 
lining  membrane  and  suture  of 
the  incision  in  the  overlying  epi- 
thelium. Compare  the  operation 
for  sebaceous  cysts  of  the  head, 
given  on  page  68. 

Cysts  of  the  Testicle.  — 
Retention  cysts  of  the  testicle  are 
not  so  very  rare.  They  are  usually  round,  tense,  fully  movable, 
and  situated  in  or  near  the  upper  end  of  the  epididymis.  Ana- 
tomically they  may  be  connected  with  the  testis  or  epididymis  or 
the  fetal  remains  of  this  vicinity,  the  paradidymis  so  called.  They 
rarely  reach  an  inch  in  diameter,  and  are  usually  single,  but 
may  be  multiple.  The  contained  fluid  is  pearly  or  whitish,  and 
occasionally  contains  spermatozoa.  Such  a  cyst  in  all  but 
the  contained  fluid  closely  resembles  a  hydrocele  of  the  cord  (see 
p.  240). 

Treatment. — Aspiration  is  usually  performed  to  establish  the 
diagnosis.  It  may  be  followed  by  the  injection  of  a  few  drops  of 
carbolic  acid  or  the  cyst  may  be  dissected  out  through  a  short 
scrotal  incision. 


Fig.  121. — Cyst  <>f  Prepuce  Follow- 
ing Circumcision  in  a  Patient  of 
Four  Years  of  Age. 


SOLID   TUMORS   OF   THE   EXTERNAL   GENITALS 

Papilloma. — Multiple  papillomata  of  the  penis  are  often 
called  venereal  warts  because  they  may  follow  an  attack  of  gonor- 
rhea, though  not  necessarily  so.  They  are  usually  found  in  the 
uncleanly  or  those  wTho  are  unable  to  retract  the  foreskin,  and  are 


EPITHELIOMA  233 

situated  in  the  neighborhood  of  the  corona.  They  are  small,  ses- 
sile or  pedicled,  and  generally  multiple.  They  cause  no  pain,  do 
not  lead  to  ulceration,  and  annoy  the  patient  merely  by  their  pres- 
ence. The  best  treatment  is  to  snip  them  off  with  a  pair  of  sharp 
scissors,  and  to  cauterize  the  stumps  with  a  little  chromic  acid 
after  the  bleeding  has  been  stopped  by  pressure.  These  warts  may 
also  occur  about  the  anus. 

Epithelioma  is  by  far  the  most  common  form  of  malignant 
disease  connected  with  the  external  genital  organs.      It  usually 


Fig.   122. — Squamous  Celled  Carcinoma  of  Penis. 

begins  near  the  corona,  either  upon  the  mucous  membrane  of  the 
penis  or  foreskin  (Fig.  122).  It  may,  however,  occur  about  the 
meatus.  It  may  also  begin  in  the  scrotum,  especially  in  the  case 
of  workers  in  paraffin  and  those  who  become  covered  with  soot. 
Hence  the  name  "  chimney-sweep's  cancer."  It  presents  the  char- 
acteristics of  epithelioma  of  the  skin  in  any  part  of  the  body. 
Upon  the  head  of  the  penis  it  usually  begins  to  grow  upward  before 
it  ulcerates  so  that  it  looks  like  a  wide-spreading  wart,  but  sooner 
or  later  it  will  lead  to  hemorrhage  and  ulceration  and  present  more 
nearly  the  usual  picture  of  cancer. 

If  the  foreskin  is  retractable  a  mistake  in  diagnosis  is  scarcely 
possible.  If  there  is  felt  through  an  irretractable  foreskin  a  hard, 
tender  mass  in  the  vicinity  of  the  corona,  the  foreskin  should  be 


234       TUMORS    OF   THE    .MALI-    GENITO   I  IJINAKY    OIUJANS 

at  once  incised  so  as  to  allow    of  its  retraction  and  an  accurate 

diagnosis. 

The  lymphatic  inguinal  glands  may  not  become  affected  for 
some  months  after  the  appearance  of  the  tumor  in  the  penis.  This 
justifies  the  hope  that  an  early  excision  of  the  disease  will  com- 
pletely effect  a  cure,  and  statistics  show  that  this  hope  is  a  rea- 
sonable one. 

Treatment. — The  treatment  of  cancer  of  the  penis  is,  of 
course,  its  early  removal.  This  necessitates  amputation  of  the 
penis  in  nearly  all  cases.  The  glands  in  both  groins  should  also 
be  removed. 

Epithelioma  of  the  scrotum,  if  small  and  freely  movable  upon 
the  underlying  tissues,  is  easily  excised.  Owing  to  the  great  flexi- 
bility of  the  tissues  there  is  no  excuse  for  not  removing  with  the 
tumor  a  wide  margin  of  apparently  healthy  skin.  The  lymphatic 
glands  likely  to  be  involved  in  cancer  of  the  scrotum  are  those  of 
the  inguinal  region.     They  should  also  be  removed. 

Sarcoma  or  Carcinoma  of  Testicle. — Malignant  disease 
of  the  testicle  is  not  so  very  rare.  It  is  of  the  utmost  importance 
to  recognize  it  early.  In  the  early  stages  of  the  disease  the  testicle 
is  swollen,  smooth,  but  much  harder  and  heavier  than  normal. 
There  is  little  or  no  pain,  but  a  sense  of  weight.  As  the 
disease  progresses  it  may  infiltrate  the  surrounding  tissues  and 
involve  the  skin.  Even  before  this  the  superficial  vessels  are 
much  dilated. 

Sarcoma  or  carcinoma  is  easily  distinguishable  from  hydro- 
cele by  the  light  test.  This  is  the  more  important  as  a  vascular 
tumor  will  often  give  a  feeling  of  fluctuation,  but  no  matter  how 
vascular  it  is  there  will  be  little  or  no  translucency.  It  should  be 
borne  in  mind  that  hydrocele  may  be  secondary  to  this  and  other 
severe  lesions  of  the  testicle.  The  collection  of  fluid  is  usually 
small,  and  ought  in  no  instance  to  conceal  the  severer  lesions  from 
a  careful  observer. 

Sarcoma  and  syphilis  have  many  points  in  common.  The  his- 
tory of  syphilis  as  opposed  to  that  of  injury,  and  the  beneficent 
effect  of  treatment  by  potassium  iodid  as  opposed  to  a  continued 
growth  in  spite  of  treatment,  are  aids  in  differential  diagnosis  (see 
also  p.  228).  Treatment  consists  in  the  immediate  removal  of  the 
affected  testicle,  with  cord  and  inguinal  glands. 


TUMORS   OF  THE   PROSTATE:   PROSTATIC   HYPERTROPHY     235 

Castration. — This  operation  may  be  performed  under  a  local 
or  a  general  anesthetic.  The  latter  is  preferable  in  malignant 
cases,  as  the  dissection  should  then  be  carried  well  up  into  the 
groin. 

In  non-malignant  cases  the  skin  of  the  scrotum  should  be 
cleansed  and  shaved,  and  the  penis  wrapped  in  gutta  percha  tissue 
or  sterile  gauze.  An  incision  parallel  to  the  cord  should  be  made 
from  the  external  ring  downward  for  an  inch  or  more.  After  divi- 
sion of  skin,  cremaster,  and  fascia,  the  testicle  can  be  brought  out 
of  the  wound.  If  there  is  any  doubt  as  to  the  nature  of  the  dis- 
ease, the  testicle  should  be  incised.  If  it  is  decided  not  to  remove 
it,  the  incision  may  be  sutured.  This  step  is  important,  for  cas- 
tration has  been  performed  in  cases  of  hematocele  and  even  hydro- 
cele, a  wrong  diagnosis  having  been  made. 

The  attachment  of  testicle  to  the  bottom  of  the  scrotum  is  next 
to  be  divided.  The  testicle  is  then  withdrawn  from  the  wound 
and  removed  with  so  much  of  the  cord  as  conditions  make  neces- 
sary. There  are  three  arteries  to  ligate — the  cremastric,  the  sper- 
matic, and  the  artery  of  the  vas  deferens — and  several  veins.  The 
stump  of  the  vas  may  be  touched  with  carbolic  acid,  or  a  cautery  in 
infective  cases.  Skin  involved  by  disease  should  be  removed  and 
healthy  skin  sutured.  If  a  small  gutta  percha  drain  is  placed  in 
the  lower  angle  of  the  wound  or  through  the  bottom  of  the  scro- 
tum, it  should  be  removed  in  two  days,  or  as  soon  as  the  serous 
flow  becomes  scanty,  so  that  a  sinus  may  not  be  formed. 

TUMORS   OF   THE   BLADDER  AND   PROSTATE 

Tumors  of  the  Bladder. — Tumors  of  the  bladder  may  be 
either  benign  or  malignant.  They  are  apt  to  be  papillomatous, 
and  first  attract  attention  either  by  obstructing  the  flow  of  urine 
or  by  giving  rise  to  hemorrhage.  Their  diagnosis  and  treatment 
are  often  extremely  difficult,  and  form  an  important  chapter  in 
major  surgery. 

Tumors  of  the  Prostate :  Prostatic  Hypertrophy. — 
Tumors  of  the  prostate  are  rare  unless  one  considers  as  a  tumor 
the  chronic  enlargement  of  the  prostate  so  often  found  in  men 
past  middle  age.  This  may  remain  unnoticed  until  its  infringe- 
ment on  the  urethra  causes  delay  in  starting  the  stream,  a  feeble 


236        TUMORS   OF   THE   MALE    UKMTO-URINARY   ORGANS 

stream,  and  dribbling  at  the  end.  Where  enlargement  is  more 
marked  symptoms  of  urethritis  and  cystitis  are  added,  and  sooner 
or  later  the  patient  is  likely  to  suffer  from  inability  to  pass  water. 
Hence  prostatic  hypertrophy  ought  always  to  be  borne  in  mind 
under  such  circumstances  if  the  patient  is  over  forty  years  of  age. 
If  the  enlargement  is  not  too  great  or  does  not  press  forward  too 
sharply  against  the  urethral  canal,  a  soft  rubber  catheter  can 
usually  he  passed  to  the  bladder  and  the  patient  be  thus  tempo- 
rarily relieved.  If  this  is  not  possible  the  surgeon  may  suc- 
ceed in  passing  a  silver  instrument  bent  in  an  extra  large  curve, 
the  so-called  prostatic  curve.  Failing  in  this,  he  must  resort 
to  some  of  the  measures  spoken  of  under  the  caption  "  Reten- 
tion of  Urine  "  (p.  219).  In  the  early  stages  of  this  difficulty, 
the  administration  of  urotropin  or  one  of  the  various  manu- 
factured medicines  which  contain  it,  will  often  cause  the 
prompt  disappearance  of  the  symptoms.  The  relief  thus  obtained 
is,  of  course,  not  permanent,  but  it  may  last  some  weeks  or  months. 
When  the  prostatic  enlargement  again  forces  itself  into  notice, 
daily  catheterization  and  irrigation,  or  cauterization  of  the  pros- 
tate through  the  urethra  (Bottini's  method),  or  prostatectomy  car- 
ried out  through  a  suprapubic  or  perineal  incision  must  be  con- 
sidered. The  description  of  these  operations  will  be  found  in 
detail  in  books  on  major  surgery.  Castration  was  at  one  time 
extolled  as  a  means  of  reducing  enlargement  of  the  prostate,  but 
it  has  not  proved  successful  in  most  cases. 

ACQUIRED    DEFORMITIES 

Hydrocele. — Hydrocele  is  an  accumulation  of  fluid  in  the 
tunica  vaginalis  (Figs.  123  and  124).  It  may  occur  at  any  age 
and  be  unilateral  or  bilateral.  It  may  follow  an  injury  or  may 
accompany  inflammatory  conditions,  but  in  most  cases  no  cause  for 
it  is  apparent. 

Diagnosis. — Symptoms,  if  any,  are  due  to  the  increased 
weight  which  drags  upon  the  cord.  Usually  a  hydrocele  is  readily 
recognized.  If  the  accumulation  of  fluid  is  moderate,  there  will 
be  felt  alongside  of  and  partly  overlapping  the  testicle  a  flabby, 
fluctuating  cyst.  If  the  accumulation  of  fluid  is  greater,  the  tunica 
will  be  distended,  and  the  cyst  thus  formed  will  be  tense  and  flue- 


HYDROCELE 


237 


tuating,  while  the  exact  location  of  the  testicle  may  be  uncer- 
tain.    If  the  tunica  is  fully  distended  the  whole  swelling  is  pear- 


Fig.    123. — Small    Hydrocele.     Duration    four    months.     Patient    aged    sixty-two 

years. 

shaped,  the  small  end  being  upward.  A  fluctuation  wave  is  easily 
obtained  if  the  mass  is  grasped  in  one  hand  and  tapped  with  a 
finger  of  the  other  hand  first  in  one  place  and  then  in  another. 


Fig.  124. — Hydrocele  of  Ten  Years'  Duration.     Growing  most  in  the  past  two 
years.     Never  treated.     Patient  aged  fifty-seven  years. 


238     DEFORMITIES  OF  THE  MALE  GENITOURINARY  ORGANS 

A  hydrocele  may  usually  be  diagnosed  by  palpation.  Occasion- 
ally, however,  even  the  most  skilful  fingers  will  be  deceived,  so  that 
in  every  case  the  light  test  should  be  employed.  This  depends  upon 
the  fact  that  light  is  more  readily  transmitted  through  serum  than 
through  a  blood  clot,  a  hernia,  a  swollen  testicle,  or  a  fleshy  tumor, 
these  being'  the  conditions  most  likely  to  be  mistaken  for  hydro- 
cele. The  test  is  applied  as  follows :  A  tube  about  a  foot  long  and 
one  inch  or  less  in  diameter  is  pressed  against  one  side  of  the 
elevated  tumor,  while  the  surgeon  puts  his  eye  close  to  the  other 
end  of  the  tube.  A  light  is  so  held  that  its  rays  may  pass  through 
the  tumor  and  tube  to  the  eye  of  the  surgeon.  Daylight  may  be 
employed  for  this  purpose,  but  is  by  no  means  so  accurate  as  Con- 
centrated artificial  light.  This  test  will  serve  not  only  to  distin- 
guish a  hydrocele  from  other  swellings,  but  will  show  the  position 
of  the  testicle  and  will  thus  enable  the  operator  to  avoid  it  in 
thrusting  in  a  trocar  for  the  purpose  of  aspirating  the  fluid.  The 
light  test  is  more  delicate  when  performed  in  a  darkened  room. 
(For  diagnosis  of  hematocele  see  page  204.) 

Hydrocele  differs  from  hernia  in  that  the  inguinal  canal  is 
empty,  there  is  no  cough  impulse,  the  tumor  is  irreducible,  yields 
an  exquisite  wave  of  fluctuation,  and  generally  transmits  light. 
Hernia  aud  hydrocele  may  coexist. 

A  chrome  hydrocele  is  differentiated  from  an  inflamed  testicle 
by  its  fluctuation  and  translucency,  and  by  the  presence  of  the 
normal  uniuflamed  testicle,  and  by  the  absence  of  pain.  An  acute 
hydrocele  is  often  a  result  of  inflammation  or  injury  of  the  testicle, 
but  the  amount  of  fluid  is  small  in  these  cases. 

Hydrocele  is  differentiated  from  a  solid  (usually  malignant) 
tumor  by  the  absence  of  pain,  by  the  better  wave  of  fluctuation, 
and  by  translucency.  Moreover,  the  solid  tumor  will  weigh  more 
iu  proportion  to  its  size  and  will  produce  dilatation  of  the  blood- 
vessels and  possibly  enlargement  of  the  inguinal  glands.  A  final 
diagnostic  test  is  the  aspiration  of  serous  fluid. 

Treatment. — The  simplest  treatment  for  hydrocele  is  the 
aspiration  of  its  contents.  As  the  fluid  usually  reaccumulates  in  a 
few  weeks,  it  is  better  in  every  instance  after  the  aspiration  of  the 
fluid  to  inject  a  small  quantity  (five  to  thirty  minims,  according 
to  the  size  of  the  hydrocele)  of  tincture  of  iodine  or  pure  carbolic 
acid.     This  causes  for  a  few  minutes  a  burning  sensation  which  is 


HYDROCELE  239 

not  unendurable.  In  a  day  or  so,  owing  to  the  effect  of  the  irri- 
tation, the  testicle  and  tunica  may  swell  until  the  tumor  is  almost 
as  large  as  before  aspiration.  The  swelling  gradually  decreases, 
however,  and  in  a  majority  of  instances  the  hydrocele  does  not 
recur.  The  patient  should  be  informed  of  this  inflammatory  reac- 
tion, otherwise  he  may  believe  that  the  hydrocele  has  promptly 
recurred  and  will  probably  seek  other  medical  advice. 

The  aspiration  and  injection  can  easily  be  performed  at  the 
surgeon's  office  as  follows:   The  patient  should  lie  on  his  back. 
The  scrotum  should  be  carefully  washed  and  made  surgically  clean. 
It  should  be  supported  and  distended  by  an  assistant,  while  the 
surgeon  plunges  the  needle  of  a  hypodermic  syringe  into  the  tunica 
at  some  point  far  removed  from  the  testicle,  which  ordinarily  lies 
in  the  lower  posterior  portion  of  the  tumor.      Serous  fluid  will 
immediately  flow  from  the  needle,  which  should  be  left  in  posi- 
tion, as  the  iodine  or  carbolic  acid  is  subsequently  to  be  injected 
through  it.     A  small  sized  trocar  and  cannula  are  thrust  into  the 
tunica  near  the  hypodermic  syringe.      The  trocar  is  withdrawn 
and    the    hydrocele   fluid    allowed    to    escape.      The    hypodermic 
syringe  containing  the  fluid  to  be  injected  is  then  screwed  on  to 
the  hypodermic  needle  and  the  injection  is  slowly   made.      The 
cannula  and  hypodermic  needle  are  then  withdrawn  and  the  punc- 
tures covered  with  a  little  gauze,  which  is  strapped  to  the  scrotum 
and   a   suspensory  bandage   is   applied.      The   advantages  of  this 
method  of  procedure  are  two :  the  introduction  of  the  hypodermic 
needle  causes  little  pain  and  further  confirms  the  diagnosis,  while 
the  presence  of  the  two  instruments  enables  the   surgeon  to  be 
absolutely  sure  that  their  points  are  still  within  the  tunica  vagi- 
nalis before  he  injects  the  iodine  or  carbolic  acid,  for  they  can 
be  rubbed  together  and  will  produce  a  distinct  click.     Another 
good  plan  is  to  tap  the  hydrocele  with  a  small  trocar,  to  withdraw 
the  same,  and  when  the  fluid  has  run  off  through  the  cannula  to 
pass  through  it  a  second  still  smaller  hollow  blunt  needle  affixed 
to  the  syringe  containing  the  carbolic  or  iodine.     In  this  way  the 
dosage  of  the  injected  fluid  may  be  made  accurate,  as  none  is  lost 
in  the  cannula.     Unless  some  such  method  is  employed  it  may  hap- 
pen that  the  collapsed  tunica  retracts  over  the  point  of  the  cannula, 
allowing  the  injected  fluid  to  pass  into  the  scrotum  outside  of  the 
tunica. 


240     DEFORMITIES   OF   THE   MALE   GENITO-URINARY   ORGANS 

A  hydrocele  may  recur  after  injection.  This  is  the  rule  if  a 
very  small  quantity  of  fluid  is  injected,  but  the  reaction  after  a 
small  injection  is  very  slight,  so  that  a  repetition  of  the  aspiration 
and  the  injection,  perhaps  three  or  more  times,  is  not  objection- 
able. By  this  treatment  the  patient  loses  no  time  from  his  busi- 
ness and  there  is  always  a  good  chance  that  the  second  or  third 
injection  may  effect  a  cure. 

Should  a  more  radical  treatment  be  desired,  it  may  be  carried 
out  as  follows:  Make  an  incision  through  the  skin  of  the  scrotum 
anteriorly,  parallel  to  the  long-  axis  of  the  body,  extending  from 
the  upper  end  of  the  whole  swelling  to  a  little  below  its  middle. 
It  will  be  necessary  to  divide  several  layers  of  fascia  and  thin 
muscle  (dartos)  before  exposing  the  tunica  vaginalis.  This  should 
be  incised  throughout  nearly  its  whole  length.  The  fluid  is  fully 
evacuated,  surplus  portions  of  the  sac  are  removed,  and  the  edges 
of  the  sac  so  stitched  to  the  edges  of  the  skin  that  the  sac  remains 
open.  Its  cavity  is  filled  loosely  with  gauze,  and  allowed  to  heal 
by  granulation. 

Another  method  of  operating  consists  in  the  removal  of  the 
greater  part  of  the  parietal  portion  of  the  sac.  The  visceral  por- 
tion should  be  lightly  scratched  with  a  needle  to  facilitate  adhe- 
sions between  it  and  the  subcutaneous  tissue.  The  wound  may  be 
closed  either  partially  or  wholly. 

These  severer  operations  require  the  patient  to  remain  in  bed 
for  some  days. 

Unusual  Types  of  Hydrocele. — In  the  hydrocele,  as  de- 
scribed above,  the  fluid  collects  in  the  normal  tunica  vaginalis. 
There  are  several  other  varieties  of  hydrocele. 

Congenital  Hydrocele. — The  cavity  of  the  tunica  vaginalis  may 
extend  upward  as  far  as  the  internal  abdominal  ring,  or  may  even 
connect  with  the  cavity  of  the  peritoneum.  Under  such  circum- 
stances the  opening  is  usually  small,  but  pressure  upon  the  hydro- 
cele, if  the  patient  is  in  a  recumbent  position,  will  cause  the  fluid 
to  disappear  into  the  abdominal  cavity.  It  will  reaccumulate 
when  the  patient  resumes  an  upright  position. 

Hydrocele  of  the  Cord. — Fluid  may  collect  in  some  unobliter- 
ated  portion  of  the  peritoneal  process  which  accompanies  the  de- 
scent of  the  testicle.  This  is  called  a  hydrocele  of  the  cord.  A 
hydrocele  of  the  cord  may  coexist  with  hydrocele  of  the  tunica 


VARICOCELE  241 

vaginalis,  the  two  sacs  being  entirely  distinct  and  possibly  sepa- 
rated by  an  inch  or  more  of  normal  cord,  or  the  hydrocele  of  the 
cord  may  exist  alone,  or  there  may  be  more  than  one  hydrocele  of 
the  cord. 

The  diagnosis  of  these  conditions  is  sometimes  easy,  sometimes 
difficult.  They  are  most  likely  to  be  confused  with  hernia.,  if 
the  hydrocele  extends  into  the  inguinal  canal  an  impulse  in  the 
tumor  may  be  produced  by  coughing.  Again,  the  possibility  of 
reducing  the  fluid  iuto  the  peritoneal  cavity  may  be  misleading, 
but  the  fact  that  it  reaccumulates  when  the  patient  stands  upright, 
even  though  the  finger  of  the  surgeon  be  lightly  pressed  upon  the 
external  ring,  will  usually  suffice  for  a  correct  diagnosis.  A  her- 
nia may  coexist  with  a  hydrocele,  and  here  again  the  diagnosis 
may  be  easy  or  difficult  (see  pp.  194  and  238). 

If  the  hydrocele  of  the  cord  is  situated  low  down,  it  may  be 
impossible  to  differentiate  it  from  a  cyst  of  the  epididymis  except 
by  aspiration.  The  fluid  in  these  cysts  is  pearly  or  milky  white, 
while  that  in  a  hydrocele  is  straw-colored. 

Treatment  may  be  by  aspiration  and  injection  of  a  few  drops 
of  carbolic  acid  or  iodine ;  but  on  account  of  the  difficulty  of  exact 
diagnosis  in  many  of  these  cases,  it  is  better  to  expose  the  sac 
through  a  short  skin  incision,  to  dissect  it  free  and  to  remove  it, 
and  suture  the  wound.  In  this  way  one  avoids  the  chance  of 
doing  injury  by  aspiration  and  injection.  It  is  better  that  the 
patient  should  go  to  bed  for  a  week  or  two,  with  a  reasonable  cer- 
tainty of  cure,  than  that  he  should  be  subjected  to  danger  because 
the  surgeon  is  working  in  the  dark. 

Varicocele. — Another  common  abnormal  condition  within  the 
scrotum  is  varicocele.  The  essential  feature  of  varicocele  is  a 
lengthening,  dilatation,  and  contortion  of  the  veins  accompanying 
the  spermatic  cord  (Figs.  125  and  126). 

Varicocele  is  almost  exclusively  found  upon  the  left  side.  A 
number  of  reasons  have  been  given  to  explain  this.  It  has  been 
pointed  out  that  the  left  spermatic  vein  is  longer  than  the  right 
and  empties  into  the  left  renal  at  a  right  angle,  whereas  the  ter- 
mination of  the  right  vein  is  in  the  vena  cava,  and  the  angle  is 
oblique. 

It  seems  probable  that  modern  clothing  has  something  to  do 
with  the  development  of  varicocele  on  the  left  side.     The  almost 


242     DEFORMITIES   OF  THE   MALE   GEXITO-URINARY   ORGANS 

invariable  habit  men  have  of  placing  botli  testicles  and  the  penis 
in  the  left  leg  of  the  trousers  may  drag  upon  the  left  cord  so  as 
to  interfere  with  its  circulation.     At  least  the  writer  has  known 


Fig.  125. — Varicocele  of  Moderate  Degree.     Duration,  one  year.     Patient  aged 

thirty-six  years. 

the  pain  from  a  moderate  varicocele  to  disappear  soon  after  the 
patient  made  it  a  practice  to  put  testicles  and  penis  in  the  right 
leg  of  the  trousers,  thus  giving  the  support  of  the  seam  to  the 
weaker  (left)  organ. 

Keyes  calls  attention  to  the  fact  that  varicocele  is  almost  exclu- 
sively a  condition  of  young  unmarried  men,  and  frequently  dis- 
appears within  a  short  time  after  marriage. 

The  veins  first  affected  are  usually  situated  just  above  the 
testicle  or  by  the  side  of  its  upper  portion.  They  may  also  extend 
well  up  to  the  external  ring.  A  well  marked  varicocele  has  been 
aptly  compared  to  a  bag  of  earthworms  from  the  sensation  pro- 
duced upon  the  palpating  thumb  and  finger.    If  the  veins  are  very 


VARICOCELE 


243 


large  there  may  be  some  impulse  on  coughing.     The  size  of  the 
tumor  will  be  considerably  reduced  when  the  patient  lies  down. 

The  symptoms  produced  in  the  patient  are  a  dragging,  heavy 
sensation,  often  associated  with  more  or  less  constant  pain  in  the 
testicle  and  cord,  and  possibly  in  the  penis.  Aside  from  this  local 
discomfort  the  patient  is  often  distressed  by  the  thought  that  the 
continuance  of  the  trouble  will  affect  his  virility.  This  does  not 
appear  to  be  true,  although  the  atrophy  of  the  corresponding  tes- 
ticle often  seen  in  connection  with  a  long  standing  varicocele  sug- 
gest this  idea.  The  scrotum  will  usually  be  found  relaxed  to  an 
uncomfortable  extent.  These  local  disturbances,  combined  with  the 
mental  distress,  often  affect  the  general  health  of  the  patient. 


f :                                                             '  :  ',.'■■        '  .                      ( 

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m 

Fig.  126. — Varicocele  of  Extreme  Degree.     Veins  unusually  large  and  distinct. 
Duration,  fourteen  years.     Patient  aged  twenty-nine  years. 

Teeatment. — In  many  cases  relief  follows  the  use  of  a  sus- 
pensory bandage,  cold  bathing  and  attention  to  the  general  health, 
18 


244     DEFORMITIES   OF   THE   MALE   GENITOURINARY   ORGANS 

and  particularly  to  the  condition  of  the  bowels.    When  these  simple 
measures  fail  to  bring  relief,  operation  is  indicated. 

There  are  several  forms  of  operation  which  have  proved  suc- 
cessful. They  are  all  capable  of  easy  performance  under  eucain 
or  cocain,  unless  the  nervousness  of  the  individual  makes  a  gen- 
eral anesthetic  desirable.  A  short  incision  parallel  to  the  cord  is 
made  over  the  upper  portion  of  the  dilated  veins.  The  mass  of 
dilated  veins  is  separated  from  the  surrounding  tissues  and  ligated 
in  two  places  and  divided,  lie  fore  I  lie  ligatures  are  tied  the  sur- 
geon should  convince  himself  that  they  do  not  include  the  vas 
■  deferens  by  actually  feeling  it  outside  of  the  ligature.  A  slightly 
more  extensive  operation  includes  the  dissection  of  a  part  of  or 
the  whole  mass  of  dilated  veins  and  the  careful  ligation  of  their 
stumps.  The  upper  and  lower  ligatures  may  be  tied  together,  thus 
closing  the  gap  caused  by  the  removal  of  the  veins  and  giving 
extra  support  to  the  testicle.  The  wound  in  the  skin  is  sutured 
with  fine  black  silk.  If  the  scrotum  is  lax  the  above  operation 
may  be  combined  with  removal  of  its  most  dependent  portion. 
The  major  part  of  the  excision  should  take  place  on  the  affected 
side.  The  wound  is  fully  sutured.  It  makes  no  difference  in 
which  direction  the  suture  line  in  the  scrotum  runs. 

Although  these  operations  are  simple  and  the  patient  can  walk 
home  after  their  performance,  it  is  better  for  him  to  go  to  bed 
before  operation  and  to  remain  in  bed  for  a  few  days  afterward 
to  avoid  bringing  strain  upon  the  parts  and  to  lessen  the  risk 
of  hemorrhage,  always  an  unpleasant  complication  when  it  occurs 
in  the  loose  tissues  of  the  scrotum. 

The  after-treatment  consists  in  the  wearing  of  a  suspensory 
bandage  for  a  time  and  attention  to  the  general  health.  There  is 
seldom  recurrence,  especially  if  a  considerable  part  of  the  dilated 
veins  have  been  removed. 


CONGENITAL   DEFORMITIES 

Phimosis. — The  commonest  malformation  of  the  male  geni- 
tals is  phimosis.  The  foreskin  may  or  may  not.  be  of  unusual 
length.  Its  opening  is  too  small  to  permit  the  retraction  of  the 
foreskin  over  the  head  of  the  penis  (Fig.  127).  It  may  be  so 
small  as  seriously  to  interfere  with  the  passage  of  urine.     If  the 


PHIMOSIS 


245 


opening  is  minute  the  sebaceous  secretion  around  the  corona  does 
not  readily  find  an  exit,  and  the  slight  irritation  produced  by  its 
presence  often  causes  adhesions  between  the  mucous  membrane  of 
the  head  of  the  penis  and  the  inner  layer  of  the  foreskin.  Some- 
times these  adhesions  are  easily  broken  up,  sometimes  the  two 
layers  of  epithelium  are  so  firmly  grown  together  that  ono  or  the 


Fig.  127. — Tight  Phimosis;  Congenital.     Patient  aged  sixteen  years. 

other  is  torn  away  in  the  complete  retraction  of  the  foreskin.  In 
a  more  serious  degree  of  phimosis  the  entire  space  between  the 
head  of  the  penis  and  the  foreskin  is  obliterated,  and  the  skin 
covering  the  penis  is  attached  directly  around  the  meatus. 

Teeatment. — At  birth  the  foreskin  is  so  thin  and  elastic  that 
even  though  its  opening  is  very  small,  it  can  usually  be  forcibly 
retracted.  If  gauze  is  employed  to  prevent  the  foreskin  from  slip- 
ping through  the  surgeon's  fingers,  less  force  is  necessary.  The 
passage  of  a  thin,  flat  probe  between  the  foreskin  and  the  glans 
penis  will  be  found  useful  in  breaking  up  any  existing  adhesions. 
Or  the  foreskin  may  be  drawn  forward  and  its  opening  enlarged  by 
inserting  in  it  the  beak  of  a  pointed  closed  artery  forceps,  and  then 
separating  the  blades.  The  foreskin  should  then  be  retracted  and 
the  head  of  the  penis  smeared  with  a  bland  ointment  to  prevent 


246     DEFORMITIES  OF  THE   MALI-:   GENITOURINARY   ORGANS 

the  formation  of  adhesions.  The  foreskin  should  then  be  again 
drawn  over  the  glans,  and  never  left  retracted  lest  paraphimosis 
be  produced  (p.  205).  This  treatment  should  be  repeated  every 
few  days  until  the  tendency  toward  retraction  is  outgrown. 

Operative  treatment  for  phimosis  consists  in  making  a  dorsal 
incision  or  two  lateral  incisions  through  the  foreskin  so  as  to  in- 
crease the  size  of  the  orifice;  or  in  the  removal  of  a  wide  circle 
of  skin  about  the  orifice.  Tins  last  operation  is  called  circum- 
cision. 

Incision  of  the  Foreskin. — A  dorsal  incision  is  a  temporary 
expedient  to  be  resorted  to  in  the  presence  of  inflammation  or 
edema,  especially  when  the  foreskin  has  been  drawn  back  beyond 
the  corona  of  the  glans  and  cannot  be  brought  over  it  again.  It 
leaves  an  unsightly  deformity,  and  should  always  be  considered 
merely  a  temporary  measure.     It  is  performed  as  follows: 

If  the  foreskin  is  retracted,  the  tightest  portion  is  obscured 
between  the  looser  folds  of  skin  of  the  inner  and  outer  portions 
of  the  prepuce.  These  roll  up  in  two  rings  of  edematous  skin. 
By  separating  them  the  tense  constricting  ring  will  be  revealed. 
A  few  drops  of  cocain  solution  should  be  injected,  and  as  soon 
as  anesthesia  has  developed  the  tight  ring  should  be  seized  with 
mouse  tooth  forceps  and  cut  through  with  scissors  or  a  scalpel,  and 
the  incision  continued  upward  and  downward  sufficiently  to  enable 
one  to  draw  the  foreskin  down  over  the  head  of  the  penis.  When 
this  is  done  it  is  easier  to  estimate  the  amount  of  division  which 
is  necessary.  In  general  the  inner  layer  of  the  foreskin  should  be 
divided'  to  the  corona ;  the  outer  layer  not  quite  so  far. 

If  the  foreskin  is  not  retracted,  as  in  many  cases  of  chancroid, 
the  injection  of  cocain  should  be  made  along  the  line  of  incision, 
first  in  the  outer  layer  of  the  prepuce  and  then  in  its  reflected 
layer.  The  blunt  point  of  a  pair  of  straight  scissors  should  then 
be  passed  between  the  head  of  the  penis  and  the  foreskin,  and  both 
layers  of  the  latter  split  up  for  half  an  inch.  The  foreskin 
should  then  be  partially  retracted,  and  a  second  cut  made  in  the 
inner  layer  of  the  foreskin  so  that  its  division  shall  be  carried 
back  to  a  point  opposite  the  corona.  This  will  enable  the  foreskin 
to  be  fully  retracted.  The  operator  must  then  judge  as  to  the 
necessity  of  any  further  division  of  the  outer  layer,  or  of  the  wis- 
dom of  an  immediate  circumcision.     This  should  certainly  be  per- 


CIRCUMCISION  247 

formed  in  non-infective  cases,  and  probably  in  many  of  the  infec- 
tive ones  as  well. 

Two  lateral  incisions  are  made  in  a  similar  manner  to  the 
single  dorsal  incision.  It  is  claimed  for  this  method  that  it  is 
never  followed  by  a  great  edema  around  the  frenum,  which  is  often 
such  an  annoying  sequel  of  the  dorsal  incision. 

Circumcision. — This  little  operation  can  be  performed  in  a 
number  of  ways.  The  practise  among  the  Hebrews  when  circum- 
cision is  performed  as  a  religious  rite  is  to  draw  the  foreskin  well 
forward,  to  cut  it  off  with  one  stroke  of  a  long  knife,  to  immerse 
the  penis  in  wine  held  in  the  mouth  of  the  rabbi  to  stop  the  hemor- 
rhage, and  then  to  wrap  it  in  linen  rags.  It  is  not  surprising  that 
dangerous  hemorrhage  and  infection  sometimes  follow  this  pro- 
cedure, and  a  few  lives  have  been  lost  in  consequence. 

Equally  reprehensible  is  the  practise  among  some  surgeons  of 
trying  to  perform  this  little  operation  in  the  shortest  possible  time. 
For  this  purpose  clamps  have  been  devised  to  hold  the  foreskin  so 
that  both  the  external  and  reflected  portions  can  be  cut  away  by 
a  single  stroke  of  the  knife.  It  is  obvious  that  the  amount  of  skin 
thus  removed  cannot  be  controlled  with  certainty,  and  even  if  the 
line  of  incision  be  a  perfectly  smooth  circular  one,  a  thing  which 
rarely  happens,  the  adjustment  in  length  of  the  external  and  in- 
ternal portions  of  the  prepuce  is  at  best  uncertain.  There  is  no 
part  of  the  body  concerning  which  most  patients  are  more  sensi- 
tive, so  that  the  surgeon  ought  to  be  willing  to  give  up  a  few 
minutes  of  his  time  in  order  to  secure  a  perfect  result. 

An  extensive  experience,  both  in  the  performance  of  this  opera- 
tion and  in  the  observance  of  the  operation  as  performed  by  others, 
has  convinced  the  writer  that  a  perfect  result  is  most  likely  to  be 
attained  in  the  following  manner :  The  patient,  if  a  very  young 
baby,  requires  no  anesthetic,  or  ether  may  be  given.  A  local  anes- 
thetic had  better  not  be  employed  in  patients  under  six  or  eight 
years  of  age,  as  it  will  not  remove  the  fright  of  an  infant  or  a 
young  child.  The  parts  should  be  carefully  washed  with  soap 
and  warm  water  and  a  weak  solution  of  bichlorid  of  mercury, 
1 :  2,000  or  weaker.  Two  sharp  nosed  artery  clamps  should  be 
fixed  upon  the  orifice  of  the  foreskin  to  the  right  and  left  of  the 
dorsal  median  line.  If  the  orifice  is  too  small  to  permit  this,  it 
should  first  be  snipped  dorsally  with  a  pair  of  scissors.     Traction 


24S     DEFORMITIES   OF   THE   MALE   GENITO-URINARY   ORGANS 

being'  made  upon  the  chimps,  the  foreskin  is  drawn  well  beyond 
the  head  of  the  penis  and  one  blade  of  a  straight  scissors  is  passed 
between  the  head  of  the  penis  and  the  foreskin.  An  incision  is 
made  which  extends  nearly  back  to  the  reflection  of  the  foreskin 


Fig.  128. — Operation  for  Phimosis.     Dorsal  and  ventral  incisions  and  two  tension 

sutures. 

(Fig.  128).  In  drawing  the  foreskin  forward  in  this  manner 
there  is  danger  that  its  outer  portion  will  he  cut  farther  back  than 
will  its  inner  portion;  hence,  after  the  first  clip  of  the  scissors 
the  traction  npon  the  clamps  should  be  relaxed  and  the  reflected 
portion  of  the  foreskin  should  be  cut  farther  if  necessary.  Two 
clamps  are  then  placed  upon  the  orifice  of  the  foreskin  at  its  lower 
edge  and  an  incision  is  made  hetween  them.  This  incision  is  far 
shorter  than  the  dorsal  one.  The  two  clamps  on  the  left  side  are 
then  drawn  outward  and  the  left  half  of  the  foreskin  is  removed, 
care  being  taken  that  the  incision  through  the  inner  layer  of  the 
foreskin  shall  be  nearly  parallel  to  the  corona  of  the  glans,  and 
that  the  incision  through  the  external  layer  shall  be  directly  oppo- 
site  to  it  when  only  slight  traction  is  made  upon  the  clamps.  The 
best  result  is  ohtained  when  the  portion  of  the  inner  layer  which 


CIRCUMCISION 


249 


is  left  is  a  third  or  a  half  of  an  inch  in  width.  The  right  half  of 
the  foreskin  is  next  cut  away.  Any  bleeding  points  are  clamped 
and  tied  if  necessary  with  very  fine  catgut.  If  the  hemorrhage 
can  be  stopped  by  pressure,  so  much  the  better.  The  edges  of  the 
external  and  internal  layers  of  the  foreskin  are  then  approximated 
by  eight  or  twelve  stitches  of  fine  black  silk  (Fig.  129).  The 
first  one  should  be  applied  at  the  frenum,  the  second  upon  the  dor- 
sum of  the  penis,  the  third  and  fourth  in  the  middle  of  the  right 
and  left  sides  respectively.  In  each  of  the  four  spaces  thus  marked 
off  two  or  three  stitches  should  be  placed.  When  sutured  in  this 
manner  the  foreskin  will  not  be  drawn  unevenly  in  any  direction. 
If  preferred,  the  stitch  at  the  frenum  and  the  dorsal  stitch  may 
be  introduced  before  the  sides  of  the  divided  foreskin  are  removed. 
These  stitches,  if  left  long,  will  serve  as  retractors.  In  infants  no 
dressing  is  required,  except  a  little  sterile  gauze  placed  between 
the  penis  and  diaper.  The  mother  should  be  told  to  keep  the  penis 
clean  by  letting  a  little  cooled  boiled  water  run  over  it  after  each 
urination.     In  four  or  five  days  the  stitches  should  be  removed. 


Fig.   129.- 


-Operation  for  Phimosis.     Circular  incisions   complete;  all  sutures 
inserted. 


Silk  is  better  than  catgut,  for  the  latter  gives  way  sometimes  and 
is,  besides,  more  irritating  to  the  tender  skin.  In  older  persons 
the  skin  should  be  well  retracted  and  a  circular  bandage  of  sterile 
gauze  wound  around  the  penis  behind  the  glans.  If  this  becomes 
soiled  with  urine  it  should  be  immediately  changed.     Attention 


250     DEFORMITIES   OF   THE    MALE   GENITO-URINARY   ORGANS 

on  the  part  of  the  patient  will  usually  prevent  this  accident.  A 
good  precaution  is  to  lie  down  to  urinate,  turning  almost  upon 
the  face.  This  prevents  any  backward  dripping  of  the  urine. 
Dressed  in  the  manner  described,  the  two  cut  edges  of  skin  are 
closely  approximated,  and  will  unite  with  the  minimum  amount 
of  adhesions. 

Complications  and  Late  Results. — Painful  Micturition. — 
The  disability  following  a  properly  performed  circumcision  is  very 
slight.  There  may  be  a  little  burning  during  the  passage  of  urine 
for  one  or  two  times.  Tn  an  adult,  if  an  erection  occurs,  it  will 
only  be  painful  in  case  the  dressing  is  too  tight.  It  can  be  relieved 
at  once  by  loosening  or  removing  the  bandage. 

Hemorrhage  is  unlikely  if  all  bleeding  points  have  been  ligated. 
If  it  does  take  place  it  is  usually  subcutaneous,  and  opportunity 
should  be  given  for  the  escape  of  the  blood  through  a  gap  in  the 
skin  incision.  If  bleeding  is  free,  and  is  not  controlled  by  digital 
pressure  or  cold,  the  skin  wound  should  be  opened  sufficiently  to 
permit  proper  ligation  of  the  bleeding  vessel.  This  does  not  delay 
complete  repair  nearly  as  much  as  the  presence  of  a  subcutaneous 
hematoma. 

Edema  is  usually  due  to  faulty  technique,  either  malapproxi- 
mation  of  the  skin,  tearing  of  the  tissues,  or  hemorrhage  beneath 
the  skin.  It  shows  itself  chiefly  about  the  frenum,  and  may  per- 
sist long  after  the  wound  is  healed.  It  will  ultimately  disappear. 
Its  disappearance  may  be  hastened  by  hot  applications,  counter- 
irritants,  pricking  with  a  glover's  needle,  etc. 

Infection. — If  the  wound  becomes  infected  it  should  be  drained 
at  once  by  the  removal  of  one  or  two  stitches,  by  soaking  the  penis 
frequently  in  a  mild,  hot  antiseptic  solution,  and  by  wet  dressings 
of  creolin  1:  200,  borolyptol  1:  4,  etc.  Retraction  is  likely  to  fol- 
low- the  removal  of  stitches,  so  that  in  a  suppurative  case  they 
should  be  allowed  to  remain  until  granulations  have  fixed  the 
skin  edges  in  contact. 

Retraction  of  the  skin  of  the  penis,  so  that  its  cut  edge  is  every- 
where separated  from  the  cut  edge  of  the  mucous  membrane,  takes 
place  in  some  cases  of  infection ;  and  sometimes  without  infection, 
if  so  much  skin  has  been  removed  that  there  is  undue  tension  upon 
the  sutures.  The  immediate  result  is  a  circular  band  of  granula- 
tions, over  which  new  epithelium  will  creep  in  the  course  of  a 


NARROW   MEATUS  251 

couple  of  weeks.  The  ultimate  result  is  generally  good,  although 
the  immediate  result  is  so  discouraging.  The  skin  of  the  penis  is 
capable  of  great  stretching,  so  that  erection  is  not  permanently 
interfered  with,  even  by  the  removal  of  too  much  skin. 

Irregularity  in  Outline. — An  uneven  section  of  the  skin  should 
be  corrected  at  the  time  of  operation,  but  if  not  noticed  then  it  is 
better  to  correct  it  by  a  subsequent  operation  than  to  allow  a 
patient  to  go  away  dissatisfied.  A  common  error  is  to  leave 
too  much  skin  at  the  frenum.  This  projects  beneath  the  tip 
of  the  penis  and  catches  the  last  drops  of  urine,  besides  being 
unsightly. 

If  circumcision  is  performed  to  aid  the  patient  in  overcom- 
ing the  habit  of  masturbation,  superfluous  skin  about  the  frenum 
should  never  be  left,  since  it  is  most  abundantly  supplied  with 
sensory  nerves,  and  especially  invites  manipulation. 

Recurrence  of  Phimosis. — If  the  inner  layer  is  left  long,  say 
half  an  inch  or  more,  and  the  suturing  or  the  dressing  has  been 
carelessly  done,  it  may  happen  that  the  inner  and  the  outer  layers 
of  the  foreskin  will  firmly  unite  for  a  distance  of  a  quarter  of  an 
inch  or  more  from  their  free  edges.  There  will  then  be  formed 
a  strong  band  of  cicatricial  tissue  completely  encircling  the  penis, 
which  by  its  contraction  may  so  reduce  the  orifice  of  the  foreskin 
as  to  render  necessary  a  second  operation. 

Short  Frenum. — The  frenum  should  not  take  all  the  strain 
when  the  skin  of  the  penis  is  retracted.  If  it  is  so  short  that  it 
does  so,  the  penis  may  be  curved  during  erection,  or  erection  may 
be  painful,  and  normal  coitus  impossible. 

Under  such  circumstances  the  frenum  should  be  put  on  the 
stretch  and  pierced  and  cut  with  a  sharp  pointed  knife,  the  edge 
of  which  is  directed  away  from  the  penis. 

Narrow  Meatus. — The  external  orifice  of  the  urethra  may 
be  narrow.  This  condition  may  be  an  accompaniment  of  phimosis 
or  it  may  exist  alone.  The  narrowing  is  not  usually  sufficient  to 
interfere  with  urination,  and  it  does  not  ordinarily  come  to  the 
surgeon's  notice  until  he  has  occasion  to  pass  instruments  or  treat 
the  patient  for  urethral  discharge.  It  is  then  an  interference  and 
should  be  divided. 

The  narrowing  of  the  meatus  is  usually  due  to  an  extension 
of  the  mucous  membrane  across  the  lower  portion  of  the  urethral 


252     DEFORMITIES   OF   THE   MALE   GENITO-URINARY   ORGANS 

orifice.  Sensibility  should  be  benumbed  by  the  application  of  a 
drop  of  strong  solution  of  cocain  (ten  per  cent)  or  the  hypoder- 
mic injection  of  a  drop  of  a  weak  solution  (one  per  cent).  The 
web  should  then  be  divided  by  a  blunt  pointed  narrow  knife  suffi- 
ciently to  make  the  caliber  of  the  meatus  fully  as  great  as  that  of 
the  urethra.  The  patient  should  soak  the  end  of  the  penis  in  hot 
mi  line,  and  separate  the  lips  of  the  meatus  once  every  day  to  pre- 
vent them  from  reuniting.  The  surgeon  should  pass  a  full  sized 
sound  through  the  meatus  twice  a  week  for  two  weeks,  to  insure 
the  full  benefit  of  the  operation. 

Hypospadias. — This  malformation  consists  in  a  defect  in  the 
lower  portion  of  the  urethra,  so  that  the  urine  is  passed  through 
a  fistula  in  the  glandular  penile  or  perineal  urethra.  Usually 
there  is  an  absence  of  urethra  distal  to  the  fistula.  There  is  often 
an  accompanying  flattening  of  the  head  of  the  penis  or  a  down- 
ward curving  of  the  whole  organ. 

Treatment. — If  the  opening  is  not  farther  back  than  the  mid- 
dle of  the  pendulous  portion  of  the  penis,  a  complete  restoration  of 
function,  both  urinary  and  procreative,  may  be  obtained  by  a 
simple  plastic  operation.  The  gutter  which  marks  the  site  where 
the  urethra  should  be  may  be  covered  by  skin  flaps  cut  from  the 
edges  of  this  gutter  and  turned  over  a  small  catheter.  The  raw 
surfaces  of  these  flaps  may  be  covered  by  the  remaining  skin  of 
the  penis  or  in  some  cases  by  flaps  from  the  prepuce,  if  any  prepuce 
is  present. 

Another  plan  of  treatment  is  to  free  by  dissection  the  existing 
urethra,  to  puncture  the  blind  distal  portion  of  the  penis,  and  to 
bring  forward  through  the  artificial  canal  thus  made  the  dissected 
urethra.  Its  elasticity  permits  it  to  be  stretched  to  twice  its  nor- 
mal length.  The  details  of  these  ingenious  operations,  and  others 
adapted  to  the  more  serious  cases  of  fistula  of  the  deeper  urethra, 
will  be  found  in  text-books  on  major  surgery  and  genito-urinary 
surgery. 

Epispadias  and  Exstrophy  of  the  Bladder. — In  epi- 
spadias the  urethra  opens  upon  the  dorsal  surface  of  the  penis. 
This  condition  is  often  associated  with  exstrophy  of  the  bladder, 
which  renders  a  perfect  restoration  of  function  by  means  of  opera- 
tion well-nigh  impossible ;  and  the  patient  is  compelled  to  resort  to 
the  constant  use  of  a  urinal. 


UNDESCENDED   TESTICLE  253 

Undescended  Testicle. — One  or  Loth  testicles  may  be  ab- 
sent from  the  scrotum,  either  in  infancy  or  adult  life.  There  is 
rarely  a  failure  of  the  testicles  to  develop,  but  usually  the  testicles 
if  not  in  the  scrotum  will  lie  in  the  inguinal  canals,  or  still  higher 
in  the  abdominal  cavity.  They  may  be  functionally  perfect. 
Their  absence  is  due  to  an  arrest  of  the  descent  of  the  testicles 
from  the  abdomen  to  the  scrotum,  which  takes  place  normally  in 
fetal  life. 

There  are  varying  degrees  of  undescended  testicle.  If  one  tes- 
ticle, is  found  in  the  inguinal  canal  of  an  infant,  but  can  be  easily 
pressed  out  of  the  canal  into  the  scrotum,  the  mother  should 
be  shown  how  to  press  it  through  the  canal  and  lightly  draw  it 
down  into  the  scrotum.  If  this  performance  is  repeated  every 
day  one  may  safely  trust  to  the  growth  of  the  parts  to  prevent  the 
testicle  from  lodging  permanently  in  the  inguinal  canal. 

In  some  infants  and  even  in  some  young  boys  the  inguinal 
canal  is  so  large  that  the  testicle,  although  it  lies  in  the  scrotum 
most  of  the  time,  may  be  pushed  up  into  the  abdomen  at  will. 
The  effect  of  gravity  and  motions  of  the  body  soon  bring  it  back 
into  the  scrotum.  If  this  condition  is  not  associated  with  hernia 
it  need  cause  no  alarm,  and  the  growth  of  the  child  may  be  safely 
trusted  to  bring  about  a  normal  state  of  affairs. 

Treatment. — If  the  testicle  is  firmly  fixed  in  the  inguinal 
canal  it  will  be  exposed  to  injury  by  reason  of  its  position,  and 
it  will  not  develop  properly  on  account  of  the  constant  pressure 
exerted  upon  it.  Attempts  should  therefore  be  made  to  bring  it 
down  into  the  scrotum,  or  at  least  to  get  it  out  of  the  inguinal 
canal  and  below  the  external  ring.  Gentle  manipulation  by  the 
surgeon  every  two  or  three  days  should  first  be  tried.  If  no 
progress  is  made  the  overlying  parts  should  be  incised  and  the 
testicle  freed,  all  of  the  tissues  of  the  cord  except  the  vas  and  the 
vessels  being  divided.  The  testicle  is  brought  down  as  far  as  the 
elasticity  of  the  remaining  portion  of  the  cord  will  permit,  and 
after  a  pouch  has  been  prepared  for  it  in  the  scrotum,  it  should 
be  sutured  to  the  subcutaneous  tissue  at  the  bottom  of  the  scrotum 
by  fine  chromicized  catgut.  These  sutures  should  of  course  be 
passed  through  the  fibrous  envelope  of  the  organ  and  not  deep 
into  its  substance.  The  inguinal  canal  should  be  strengthened  by 
sutures  if  it  is  found  weak  or  had  to  be  split  up  to  permit  the 


251      DEFORMITIES   OF   THE   MALI;   GENITO  URINARY    ORGANS 

tlra wing-  downward  of  tin.'  testicle.  After  a  few  weeks,  when  all 
inflammatory  reaction  has  subsided,  gentle  manipulation  and  trac- 
tion should  again  be  resorted  to.  This  will  complete  the  cure  in 
case  it  was  not  possible  at  the  time  of  operation  to  bring  the  testicle 
well  down  into  I  he  scrotum. 

If  the  testicle  at  operation  cannot  be  brought  out  of  the  ingui- 
nal canal,  or  if  it  is  located  under  the  skin  of  the  thigh  or  peri- 
neum, it  is  better  to  push  it  back  into  the  abdomen  and  to  close  by 
suture  the  internal  ring,  so  that  the  testicle  shall  not  be  constantly 
exposed  to  injury  and  pressure.  Within  the  abdomen  it  can  carry 
on  its  functions  normally.  For  this  reason  no  search  should  be 
made  for  a  testicle  which  is  situated  above  the  internal  ring. 

If  an  undescended  testicle  is  accompanied  by  hernia,  an  oper- 
ation for  radical  cure  of  the  hernia  should  be  performed  at  the 
same  time. 

Some  surgeons  advocate  the  removal  of  an  undescended  testi- 
cle because  of  the  fact  that  sarcoma  sometimes  develops  in  such 
an  organ.  This  is  a  small  risk,  and  removal  should  not  therefore 
be  made  a  routine  treatment,  if  the  testicle  can  be  moved  into  a 
safe  place. 


CHAPTER    X 

AFFECTIONS    OF  THE    FEMALE    GENITO-URINARY 

ORGANS 

INJURIES   AND    FOREIGN   BODIES 

Contusion. — Contusions  of  the  external  genitals  are  not  un- 
common either  as  the  result  of  blows  or  falls,  or  in  the  case  of 
young  girls  as  the  result  of  violent  attempts  at  coitus.  Bruises 
and  abrasions  and  wounds  should  receive  the  same  treatment  given 
to  these  lesions  in  other  parts  of  the  body  (pp.  2  and  13).  .  Owing 
to  the  sensitiveness  of  the  skin  and  its  exposure  to  contamination 
from  discharges,  etc.,  especial  efforts  at  cleanliness  are  recom- 
mended. 

Rupture  of  the  Hymen — The  hymen  is  frequently  rup- 
tured in  early  attempts  at  coitus,  although  usually  the  slight  tear 
is  not  serious  and  requires  no  treatment.  Sometimes  the  hemor- 
rhage is  great  enough  to  alarm  the  patient  and  may  even  require 
ligature.  Unless  the  tear  extends  beyond  the  limits  of  the  hymen 
no  suture  should  be  inserted.  Irrigation  with  hot  saline  solution 
after  urination  will  add  to  the  patient's  comfort  and  lessen  the 
risk  of  infection. 

Rupture  of  the  Vagina. — If  the  vagina  is  narrow  and 
non-elastic,  it  too  may  be  ruptured  in  violent  coitus.  Indeed  the 
rupture  may  extend  into  the  rectum.  It  may  also  be  ruptured  by 
a  fall  upon  some  sharp  object. 

The  first  step  in  treatment  is  a  complete  speculum  examination, 
in  order  to  determine  the  extent  of  the  injury.  If  the  breaks  in 
the  mucous  membrane  are  slight  it  is  better  not  to  introduce  a 
suture.  The  parts  should  be  cleaned  by  irrigation  with  a  hot 
mild  antiseptic  solution,  and  may  be  kept  from  adhering  by  a 
slender  tamponade  with  aseptic  gauze. 

Hematoma. — A  hematoma  may  be  formed  in  the  loose  cel- 
lular tissue  about  the  vaginal  orifice.     If  small,  it  may  be  left  to 

255 


256    AFFECTIONS  OF  THE  FEMALE  GENITOURINARY  ORGANS 

be  absorbed,  but  it'  large  or  near  the  surface,  a  shorl  incision 
should  be  made — one-half  inch  will  usually  suffice — and  the  blood 
clot  should  be  evacuated.  (See  the  treatment  of  hematoma  given 
on  p.  3.)  The  pressure  of  dry  aseptic  dressing  will  quickly  cause 
the  walls  of  the  cavity  to  adhere.  If  there  is  any  doubt  of  the 
asepsis  a  gutta-percha  drain  should  be  inserted.  This  should 
merely  pass  through  the  skin  and  not  till  the  cavity.  After  two 
days  it  should  be  removed,  and  nol  again  inserted  unless  suppu- 
ration has  taken  place.  If  there  is  suppuration  the  cavity  of  the 
hematoma  should  be  treated  like  that  of  an  abscess,  by  free  inci- 
sion and  light  gauze  drainage  (p.  3S). 

Acute  Laceration  of  the  Perineum.. — The  perineum  may 
be  torn  by  external  violence,  but  the  almost  invariable  cause  is 
childbirth.  The  tear  is  usually  a  straight  one  in  the  median  line 
or  near  it,  the  variation  in  different  cases  being  merely  one  of 
extent.  Slight  tears  heal  with  sufficient  exactness,  even  without 
sutures,  but  it  is  a  good  plan  to  suture  every  laceration,  as  other- 
wise some  deeper  ones  are  sure  to  be  overlooked. 

The  portion  of  the  perineum  which  tears  is  wedge-shaped,  with 
the  thin  edge  of  the  Avedge  forward.  When  torn,  therefore,  there 
are  two  surfaces  for  the  insertion  of  sutures,  namely,  the  vagina 
and  the  skin.  The  vaginal  sutures  are  the  more  important,  since 
they  should  protect  the  deeper  part  of  the  wound  from  the  lochial 
discharge.  The  Aveb  between  the  thumb  and  fingers  is  similar  to 
the  perineum.  If  it  is  cut  through  there  will  be  a  palmar  skin 
wound  and  a  dorsal  skin  wound,  corresponding  to  the  vaginal  and 
skin  wounds  in  a  perineal  tear.  Similarly,  if  the  cut  extends 
deeper,  muscles  Avill  be  divided.  If  one  bears  this  analogy  in  mind, 
in  suturing  a  torn  perineum  he  Avill  have  little  difficulty  in  the 
correct  apposition  of  the  torn  surfaces. 

Treatment. — The  proper  treatment  for  laceration  of  the 
perineum  is  the  immediate  aseptic  suture  of  the  separated  tis- 
sues in  their  normal  relation.  This  is  very  easy  under  favorable 
conditions.  If  the  patient  weighs  one  hundred  and  eighty  pounds 
and  lies  in  the  middle  of  a  low  soft  bed  and  no  trained  assistant 
is  obtainable,  the  task  is  well-nigh  impossible.  The  patient  should 
lie  on  the  back,  Avith  thighs  Avell  flexed  and  hip  close  to  the  edge 
of  the  bed  and  raised  on  a  hard  pillow.  An  anesthetic  is  a  con- 
venience, but  is  not  absolutely  necessary  in  many  cases.      The 


HEMORRHAGE  257 

labia  are  drawn  well  apart,  and  the  wounded  surface  wiped  dry 
with  a  gauze  sponge.     Blood  from  the  cervix  or  uterus  can  be  pre 
vented  from  flowing  over  the  perineal  wound  by  pushing  one  or 
two  gauze  sponges  well  up  into  the  vagina.     The  extent  of  lacera- 
tion can  then  be  accurately  seen. 

If  any  muscles  or  the  perineal  body  have  been  torn,  deep  as 
well  as  superficial  sutures  must  be  inserted.  Plain  catgut,  No.  2, 
or  ten  day  chromic  catgut,  No.  1,  is  a  good  material  for  the  deep 
suture.  It  saves  time  to  insert  it  as  a  continuous  suture.  The 
vaginal  tear  should  then  be  sutured  from  its  upper  end  down- 
ward. The  same  material  may  be  used  for  suture.  It  is  of  the 
greatest  importance  that  the  upper  end  of  the  tear  shall  be  accu- 
rately sutured.  Otherwise  fluid  may  trickle  down  into  the  wound 
and  defeat  union  altogether  or  in  part.  The  wound  in  the  skin 
should  be  sutured  with  fine  black  silk ;  or  if  it  is  desired  to  insert 
these  sutures  more  deeply,  so  that  they  shall  aid  in  holding  to- 
gether the  perineal  body,  silkworm  gut  is  an  excellent  material. 

If  the  tear  extends  into  the  rectum,  the  mucous  membrane 
of  the  latter  should  be  sutured  with  fine  black  silk,  in  addition 
to  the  muscular  and  cutaneous  sutures  mentioned  above. 

After-treatment  consists  in  keeping  the  suture  line  as  clean 
as  possible.  The  patient  may  be  catheterized ;  but  if  she  passes 
water  voluntarily,  the  line  of  sutures  should  be  cleansed  each 
time  with  sterile  water,  and  carefully  dried  with  sterile  gauze. 
The  patient  should  lie  on  her  side  and  face  a  part  of  the  time, 
and  not  continuously  on  her  back.  Non-absorbable  sutures  should 
be  removed  in  ten  days.  For  the  late  treatment  of  laceration  of 
the  perineum,  see  page  275. 

Hemorrhage. — In  the  treatment  of  hemorrhage  of  the  female 
genitals,  it  is  all  important  to  locate  its  source.  It  is  necessary  to 
insist  upon  this  point,  since  a  feeling  of  delicacy  upon  the  part 
of  the  patient  and  physician  as  well,  may  result  in  the  injudicious 
application  of  tampons  or  external  compresses  by  the  nurse  or 
patient.  The  only  rational  procedure  is  a  complete  exposure  of 
the  parts  in  a  good  light,  thorough  cleanliness,  and  the  ligation 
if  necessary  of  bleeding  vessels.  Slight  hemorrhage  can  be  con- 
trolled by  gauze  compresses,  applied  either  within  or  outside  the 
vagina  by  the  surgeon  himself,  under  the  favorable  conditions 
mentioned  above.     If  the  patient  is  sensitive  an  anesthetic  should 


258    AFFECTIONS  OF  THE   FEMALE   GENITO-URINARY   ORGANS 

be  given.  The  introduction  of  iiauxi-  within  the  uterine  cavity 
to  control  hemorrhage  is  a  procedure  rarely  required  and  one 
worthy  of  the  most  careful  antiseptic  precautions  and  subsequent 
treatment  in  bed.  The  use  of  dilute  solutions  of  suprarenal  ex- 
tract to  control  hemorrhage  has  been  spoken  of  on  page  0.  Larger 
bleeding  vessels  should  be  ligated  with  fine  catgut,  and  any  wounds 
closed   by  sutures  of  catgut  or  tine  silk. 

Rape. — A  physician  is  sometimes  called  upon  to  examine  a 
woman  or  young  girl  in  order  to  determine  whether  rape  has  been 
attempted.  lie  ought  to  exercise  great  caution  in  making  a  posi- 
tive  affirmation,  unless  the  laceration  of  the  hymen  and  possibly 
of  the  vagina  (dearly  show  a  violent  distention  of  these  parts. 
Purely  external  injuries  may  of  course  have  beeen  caused  by 
other  means.  The  microscopical  demonstration  of  semen  upon 
the  clothes  of  the  female  is  better  evidence,  but  this  is  a  subject 
for  medico-legal  experts.  On  the  other  hand,  coitus,  though 
forced,  may  leave  no  external  evidence  in  case  of  an  adult,  so  that 
a  negative  statement  should  not  be  carelessly  made.  The  doctor 
ought  rather  to  confine  himself  to  a  statement  of  the  condition 
in  which  he  finds  the  external  and  internal  genital  organs. 

Also  in  the  matter  of  a  purulent  vaginal  discharge,  which  in 
young  girls  often  excites  suspicion  that  they  have  been  improp- 
erly handled  by  some  man,  a  physician  should  be  careful  not  to 
claim  too  much.  A  purulent  discharge  of  this  character  may  or 
may  not  be  due  to  gonococci,  and,  even  if  it  is  demonstrated  to 
contain  gonococci,  it  may  have  been  set  up  by  contact  with  some 
other  female  or  by  the  use  of  a  dirty  towel,  or  in  some  other  man- 
ner than  by  attempted  coitus. 

Foreign  Bodies. — Foreign  bodies  are  frequently  introduced 
into  the  vagina  and  urethra  for  the  sake  of  sexual  excitement. 
The  patient  seldom  loses  control  of  such  objects  in  the  vagina, 
but  those  which  are  introduced  into  the  urethra  may  slip  from 
the  fingers  or  be  broken  in  the  canal,  and  thus  medical  aid  will 
have  to  be  summoned.  The  greatest  variety  of  objects  have  been 
found  under  such  circumstances,  either  in  the  urethra  or  partially 
or  wholly  within  the  bladder.  Slate-pencils,  hairpins,  and  hat- 
pins are  among  the  commonest.  The  pins  are  introduced  head 
foremost,  so  that  their  extraction  is  difficult.  Foreign  objects 
in  the  vagina  are  usually  neglected  pessaries,  or  some  objects  which 


FOREIGN    BODIES 


259 


have  been  introduced  by  the  patient  to  prevent  prolapse  of  the 
uterus. 

The  symptoms  produced  will  depend  upon  the  location  and 
character  of  the  foreign  body.  It  may  interfere  with  urination, 
or  cause  a  bloody  or  purulent  discharge,  or  set  up  inflammation 
of  the  urethra  or  bladder.  If  the  foreign  body  remains  a  long 
time  in  the  urethra  or  bladder,  it  may  become  the  core  about 
which  a  calculus  is  formed.  If  it  is  in  the  vagina  it  may  also 
become  incrusted,  or  it  may  partially  bury  itself  in  the  vaginal 
walls. 

Diagnosis. — The  diagnosis  of  a  foreign  body  is  made  partly 
from  the  symptoms  above  enumerated,  but  chiefly  from  the  results 


Fig.  130. — Urethroscope  for  Examination  of  the  Female  Urethra.  A  portion 
of  the  bladder  can  be  seen  through  such  an  instrument.  It  is  well  to  have  such 
instruments  of  three  sizes,  ranging  in  diameter  from  5  to  15  millimeters  (J  to  I  inch). 

of  physical  examination.     Digital  examination,  direct  inspection 
through  a  vaginal  speculum,  or  through  a  smaller  urethral  specu- 
lum, called  a  urethroscope  (Fig.  130),  are  the  usual  methods  em- 
19 


260    AFFECTIONS  OF  THE  FEMALE  GENITO-URINARY   ORGANS 

ployed.  When  the  foreign  body  is  in  the  bladder,  it  usually  lies 
transversely,  especially  when  the  bladder  is  empty,  since  the  long 
axis  of  the  collapsed  organ  is  transverse.  Its  presence  may  be  rec- 
ognized by  means  of  a  sound  or  by  the  finger  passed  through  the 
dilated  urethra,  or  by  the  cystoscope. 

Treatment. — The  removal  of  these  foreign  objects  affords  a 
wide  scope  for  the  ingenuity  of  the  surgeon.  If  the  foreign  body 
is  in  the  vagina,  this  canal  should  be  thoroughly  cleansed  by  irri- 
gation and  sponging  with  an  antiseptic  solution,  in  order  to  reduce 
the  risk  of  infection  in  wounds  which  may  be  made  intentionally 
or  accidentally  in  removing  the  foreign  body.  An  old  pessary 
can  usually  be  extracted  without  difficulty,  even  if  it  is  encrusted. 
Some  objects  are  best  removed  after  being  cut  into  two  or  three 
pieces. 

A  blunt  pointed  object  lying  in  the  urethra  may  possibly  be 
worked  out  of  the  canal,  a  little  at  a  time,  in  the  manner  described 
in  connection  with  foreign  bodies  in  the  male  urethra  (p.  207). 
If  a  pin  lies  in  the  urethral  canal  with  the  point  directed  out- 
ward, it  may  be  possible  to  pass  a  small  rubber  tube  into  the  ure- 
thra and  over  the  point  of  the  pin,  so  that  the  latter  can  then  be 
crowded  outward,  or  safely  grasped  with  a  slender  pair  of  for- 
ceps and  extracted.  The  adult  female  urethra  is  capable  of  dila- 
tation sufficient  to  permit  the  passage  of  the  little  finger.  This 
dilatation  not  only  facilitates  an  exact  diagnosis,  but  it  is  a  mate- 
rial help  in  the  extraction  of  foreign  bodies  by  means  of  slender 
forceps.  Small  foreign  bodies  and  calculi  can  be  extracted  whole. 
Larger  calculi  and  friable  objects  may  be  crushed  and  extracted. 
If  the  foreign  body  cannot  be  moved  through  the  moderately 
dilated  urethra,  it  is  better  to  perform  suprapubic  cystotomy  than 
to  run  the  risk  of  permanent  incontinence  by  too  great  dilatation 
of  the  urethral  canal. 

INFLAMMATIONS 

Pruritus. — An  intense  itching  of  the  vulva,  most  marked  in 
the  vicinity  of  the  clitoris,  and  associated  with  a  thickening  of  the 
skin  is  commonly  called  pruritus.  Objection  has  been  made  to 
this  word,  since  it  expresses  a  symptom  rather  than  a  distinct  dis- 
ease, but  it  serves  a  useful  purpose,  and  for  the  present  at  least 
had  better  be  retained. 


SIMPLE   VULVITIS   ANT)   VAGINITIS  261 

Pruritus  is  due  to  a  number  of  causes,  such  as  an  irritating 
vaginal  discharge,  or  to  decomposition  of  the  urine  in  diabetes, 
or  to  parasites,  such  as  pediculi  or  seat  worms.  In  other  cases 
it  is  due  to  the  use  of  drugs,  or  to  improper  articles  of  diet.  Some- 
times no  cause  for  the  itching  can  be  ascertained,  and  the  pruritus 
is  assumed  to  have  a  nervous  origin.  In  severe  cases  the  patients 
are  most  miserable,  and  scratch  and  tear  the  skin  until  it  bleeds. 

Treatment. — In  every  case  the  cause  for  the  pruritus  should, 
if  possible,  be  discovered  and  removed;  but  even  when  this  can 
be  done,  a  certain  amount  of  local  treatment  is  necessary.  The 
parts  should  be  bathed  twice  a  day  with  very  hot  water,  or  hot 
boracic  acid  solution.  This  should  be  followed  by  the  applica- 
tion of  a  five  per  cent  solution  of  carbolic  acid,  or  a  solution  of 
corrosive  sublimate,  one  grain  in  a  half  ounce  each  of  alcohol  and 
water.  Tincture  of  iodine,  or  five  per  cent  solution  of  creolin  or  of 
nitrate  of  silver,  twenty  grains  to  the  ounce,  have  also  been  used 
with  benefit.  The  folds  of  the  vulva  should  be  kept  from  contact 
by  talcum  powder  or  boracic  acid  or  dermatol ;  or  they  may  be 
separated  by  thin  layers  of  gauze  smeared  with  boracic  acid  oint- 
ment or  an  ointment  containing  menthol  or  chloral  or  cocain. 
Parasites  should  be  destroyed  by  mercurial  or  sulphur  ointments. 

In  obstinate  cases  success  has  sometimes  followed  resection  of 
the  sensory  nerves  which  supply  the  clitoris  and  labia  minora.  In 
other  cases  portions  of  the  labia  and  the  clitoris  have  been  re- 
moved. 

Eczema. — Eczema  of  the  vulva  often  follows  vulvitis  and 
pruritus.  Its  treatment  is  similar  to  that  of  eczema  in  other  por- 
tions of  the  body  (see  p.  57). 

Simple  Vulvitis  and  Vaginitis. — The  delicate  skin  about 
the  entrance  to  the  vagina  and  the  vagina  itself  may  become  in- 
flamed as  a  result  of  many  causes.  Such  predisposing  factors  as 
poor  health,  exposure  to  cold  and  wet,  and  traumatism  have  to  be 
considered,  while  more  immediate  causes  are  irritating  urine,  hem- 
orrhagic and  mucous  discharges  from  the  uterus  or  urethra,  in- 
discreet coitus,  constant  rubbing  to  relieve  pruritus,  etc.  Inflam- 
mation due  to  the  gonococcus  is  considered  on  page  262. 

The  symptoms  are  those  of  inflammation  everywhere,  edema, 
redness,  increased  heat  and  tenderness,  plus  a  mucopurulent  or 
purulent  discharge,  which  more  or  less  mats  together  the  folds  of 


2G2    AFFECTIONS   OF  THE   FEMALE   GEN1TO-URINARY    ORGANS 

-kin  and  the  hairs.  Urination  is  not  usually  attended  with  burn- 
ing, unless  gonorrhea  exists. 

Treatment. — It  is  desirable  to  know  the  cause  of  the  inflam- 
mation, and  in  every  case  in  which  lliis  is  obscure,  or  in  which  the 
inflammation  is  severe,  the  discharge  should  be  spread  on  a  glass 
slide,  dried  and  stained  for  gonococci.  Even  in  the  non-specific 
cases  precautions  should  be  taken  to  prevent  the  infection  of  other 
persons  either  by  direct  contact  or  by  the  use  of  towels,  etc.,  which 
have  been  used  by  the  patient. 

Attention  to  the  bowels,  rest,  and  frequent  bathing  of  the  in- 
flamed surfaces  with  a  boracic  acid  solution  or  one  of  aluminum 
acetate,  two  per  cent,  will  usually  cure  these  patients  in  a  few 
days  if  the  cause  of  the  inflammation  is  not  a  continuous  one. 
The  cleansing  is  best  performed  by  irrigation  both  within  and  out- 
side of  the  orifice  of  the  vagina,  and  the  solutions  should  be  as  hot 
as  can  be  borne.  In  the  case  of  little  girls,  in  whom  inflammations 
of  this  character  are  rather  common,  the  irrigation  should  be  made 
with  the  utmost  gentleness,  and  care  should  be  taken  not  to  block 
the  orifice  in  the  hymen  by  the  nozzle  of  the  syringe.  The  folds 
of  skin  should  be  carefully  dried  and  anointed  with  cold  cream  or 
boracic  acid  ointment  to  prevent  chafing. 

Acute  Gonorrhea.— Gonorrheal  Vulvitis. — The  acute  symp- 
toms of  a  gonorrheal  infection  of  the  vulva  are  similar  to  those 
of  a  simple  vulvitis  excepting  that  they  are  more  marked.  There 
is  more  or  less  constant  pain  aggravated  by  walking,  and  as  the 
urethra  is  generally  involved,  there  is  pain  on  micturition.  The 
skin  is  reddened,  possibly  excoriated  in  places,  and  there  is  a  pro- 
fuse mucopurulent  discharge.  When  this  has  been  sponged  away, 
it  will  be  observed  that  the  mucous  membrane  at  the  urethral  ori- 
fice is  red  and  swollen,  and  pressure  of  the  finger  upon  the  urethra 
will  cause  a  drop  of  pus  to  exude.  The  orifices  of  Bartholin's  ducts 
are  often  similarly  affected,  and  the  glands  themselves  may  be 
swollen  (see  p.  263).  The  diagnosis  of  gonorrhea  should  always 
be  confirmed  by  a  microscopic  examination  of  the  discharge. 

Treatment. — Gonorrheal  inflammation  of  the  vulva  is  of 
itself  not  serious,  except  in  the  case  of  young  children.  The  risk 
of  the  infection  depends  chiefly  on  its  possible  spread  to  the  bladder 
or  to  the  uterus  and  Fallopian  tubes,  and  through  them  to  the 
pelvic  peritoneum.     The  treatment  recommended  by  different  wri- 


INFLAMMATION    OF   BARTHOLIN'S   GLAND  '2M 

fcers  varies  considerably.  Some  believe  that  such  simple  local 
treatment  as  a  hot  vaginal  douche  is  capable  of  spreading  the 
infection,  and  should  not,  therefore,  be  advised.  The  majority 
take  the  opposite  view,  and  recommend  a  hot  douche  with  a  per- 
manganate solution  of  the  strength  of  one  part  of  permanganate 
of  potash  to  two  thousand  of  water ;  or  the  use  of  vaginal  tampons. 
One  plan  is  to  insert  after  the  douche  a  tampon  saturated  witli 
five  per  cent  argyrol  solution,  and  to  remove  this  in  ten  minutes, 
and  to  follow  it  by  a  tampon  saturated  with  boroglycerid  or  some 
other  astringent,  and  to  allow  this  to  remain  in  place  until  the 
next  treatment,  twelve  hours  later.  Whatever  plan  of  treatment 
is  followed,  the  patient  should  remain  absolutely  quiet  in  bed  until 
the  acute  symptoms  have  passed  over.  The  diet  should  be 
simple,  large  quantities  of  water  or  milk  should  be  given 
daily,  and  urotropin  or  some  other  urinary  antiseptic  should 
be  administered.  (Compare  the  medication  recommended  on 
page  213.) 

In  the  later  stages  of  the  disease  with  profuse  leucorrheal  dis- 
charge a  douche  of  sulphate  of  zinc  oj  and  powdered  alum  oij  to  2 
quarts  of  water  is  very  effective. 

Gonorrheal  Urethritis. — Treatment  for  gonorrheal  urethritis  in 
women  is  similar  to  that  employed  for  men.  The  solutions  used 
for  injection  through  a  blunt  pointed  syringe  may  be  somewhat 
stronger.  When  the  general  inflammation  has  subsided,  local 
areas  of  persistent  infection  may  be  touched  through  an  endoscope 
with  a  cotton  swab  wet  with  a  solution  of  silver  of  a  strength  of 
ten  per  cent  or  less. 

Inflammation  of  Bartholin's  Gland. — On  either  side  of 
the  vaginal  orifice  is  situated  the  gland  named  after  its  discov- 
erer, Bartholin.  This  gland  lies  immediately  under  the  skin,  and 
is  subject  to  infection  through  its  short  duct.  The  infection  is 
usually  of  a  gonorrheal  origin.  Swelling  of  the  mucous  membrane 
of  the  small  duct  prevents  evacuation  of  the  mucus  and  pus  from 
the  cavity  of  the  gland. 

Upon  examination  there  will  be  found  by  the  side  of  the 
vagina,  just  outside  of  the  hymen  or  its  remains,  a  smooth,  rounded, 
slightly  movable  swelling,  very  tender  on  pressure,  and  giving  an 
indistinct  sense  of  fluctuation.  If  the  inflammation  is  a  violent 
one  the  surrounding  cellulitis  will  obscure  these  signs,  or  if  the 


264      AFFECTIONS    OF   THE    FEMALE   GEN  ITU- I  ULNAR  Y    ORGANS 

suppuration  bas  broken  through  the  gland  into  the  subcutaneous 
tissue  there  will  be  the  usual  signs  of  abscess. 

Treatment. — The  skin  should  be  anesthetized  and  the  abscess 
opened  at  the  point  where  it  lies  nearest  the  surface.  When  its 
contents  have  been  evacuated,  a  small  triangular  portion  of  the 
skin  and  subcutaneous  tissue  overlying  the  abscess  should  be  cut 
away.  This  will  greatly  facilitate  subsequent  dressings,  for  if  a 
simple  straight  incision  be  made  it  will  be  found  difficult  to  rein- 
sert the  gauze  necessary  to  keep  open  the  incision  until  the  cavity 
of  the  abscess  has  granulated  from  the  bottom  upward. 

Simple  Suppuration. — The  usual  forms  of  suppuration, 
boils,  abscesses,  and  cellulitis,  may  occur  in  the  skin  of  the  exter- 
nal genitals.  The  treatment  is  similar  to  that  outlined  on  page 
34  et  seq. 

Chronic  Gonorrhea. — When  the  acute  symptoms  due  to 
gonorrhea  have  subsided  the  trouble  may  be  found  to  have 
lodged  in  the  bladder  or  cervix  uteri.  The  chief  symptoms  of 
cystitis  will  be  increased  frequency  and  urgency  of  micturition, 
with  a  sense  of  discomfort  and  heaviness  or  well  marked  pain. 
The  general  health  of  the  patient  is  a  good  deal  affected  by  this 
constant  irritation.  Daily  irrigations  of  the  bladder  with  mild 
antiseptic  solutions  should  be  practised.  Nitrate  of  silver  is  the 
favorite  remedy  for  this  purpose.  The  solution  first  used  should 
not  contain  more  than  one  part  of  this  drug  in  four  thousand  of 
water,  but  this  proportion  may  be  increased  as  the  patient  be- 
comes accustomed  to  the  drug.  Argyrol  in  solutions  of  two  per 
cent  or  more  makes  another  good  fluid  for  irrigating  the  bladder. 

If  the  gonorrheal  process  extends  to  the  cervix  and  uterus,  as 
shown  by  a  persistent  leucorrhea,  the  cervix  should  be  dilated  and 
the  lining  of  cervix  and  uterus  swabbed  with  cotton  moistened 
with  a  ten  or  twenty  per  cent  solution  of  argyrol  every  two  or 
three  days. 

Endocervicitis :  Erosion  of  the  Cervix. —  Inflammation 
of  the  cervix  uteri  may  be  due  to  congestion  of  the  uterus  caused 
by  malposition,  etc.,  or  to  laceration  or  to  gonorrhea.  There  is 
usually  an  exposure  and  hypertrophy  of  the  columnar  epithelium, 
which  gives  the  os  a  pouting  or  unnaturally  raw  red  appearance; 
hence  the  term  ulceration  is  often  used,  though  incorrectly. 

The  most  marked  symptom  of  endocervicitis  is  an  increased 


ENDOMETRITIS  265 

discharge  of  mucus  from  cervix  and  vagina  (leucorrhea).  Some- 
times there  is  a  thick  yellowish  plug  of  mucus  hanging  from  the 
os  at  all  times.  This  is  said  to  be  characteristic  of  gonorrhea,  but 
the  diagnosis  should  be  made  only  after  microscopic  examination. 
Leucorrhea  may  be  due  to  endometritis  as  well  as  endocervicitis. 
It  is  also  found  in  women  who  have  not  borne  children.  It  is  the 
symptom  of  endocervicitis  for  which  treatment  is  usually  sought. 

Treatment. — Whether  there  is  a  local  cause  for  it  or  not,  the 
state  of  the  health  has  an  important  bearing  upon  the  continuance 
of  leucorrhea,  just  as  it  has  upon  catarrh  of  other  mucous  mem- 
branes, and  the  treatment  of  the  patient  should  always  include 
directions  calculated  to  improve  the  general  health.  Local  treat- 
ment consists  in  the  use  of  hot  vaginal  douches  once  or  twice  a 
day.  The  fluid  used  for  this  irrigation  may  be  pure  water  or  a 
weak  solution  of  carbolic  acid  (one  teaspoonful  to  the  quart) 
or  any  other  antiseptic  or  astringent  solution.  To  the  astringent 
action  of  douches  may  be  added  that  of  drugs  placed  upon  a  cotton 
tampon  and  applied  through  a  speculum  directly  to  the  cervix. 
Ichthyol,  ten  per  cent  in  glycerin,  tannic  acid,  and  glycerin  and 
iodine  are  favorite  remedies.  Applications  of  nitrate  of  silver,  ten 
to  twenty  per  cent,  may  be  made  to  the  cervical  canal.  If  there  is 
any  malposition  of  the  uterus  or  laceration  of  the  cervix  or  any 
other  condition  which  may  tend  to  prolong  the  discharge,  it  should 
be  made  the  object  of  special  treatment,  the  details  of  which  will 
be  found  in  text-books  on  gynecology. 

Gonorrheal  endocervicitis  is  particularly  difficult  to  cure.  The 
canal  may  be  touched  with  strong  solutions  of  silver,  or  antiseptics 
and  astringents  may  be  introduced  in  the  form  of  suppositories 
into  the  uterine  cavity.  Amputation  of  the  cervix  is  frequently 
necessary  to  bring  about  a  cure. 

Endometritis. — There  are  various  forms  of  endometritis, 
both  acute  and  chronic,  but  the  common  form  and  the  only  one 
which  will  be  considered  here  is  the  hyperplastic  form,  marked 
by  chronic  congestion  with  thickening  of  the  mucous  membrane 
which  lines  the  uterus.  It  has  various  causes,  among  which  con- 
stipation, stenosis  of  the  cervix,  uterine  displacement  and  cervical 
laceration  are  the  chief. 

The  symptoms  are  an  abnormal  discharge  of  blood  either  at 
the  menstrual  period  or  at  other  times,  and  a  discharge  of  mucus — 


266    AFFECTIONS   <>K   THE   FEMALE   UENITO-URINARY    ORGANS 

leucorrhea,  which  for  the  most   pari   is  due  to  the  accompanying 
endocervicil  is. 

Diagnosis  is  made  from  the  symptoms,  from  bimanual  exami- 
nation, and  from  examination  through  a  speculum.  The  uterus 
is  enlarged  and  soft,  and  may  be  variously  displaced.  Mucus  pro- 
trudes in  many  cases  from  the  eroded  cervix  (see  p.  264).  Pas- 
sage of  a  probe  shows  an  elongation  of  the  uterine  canal,  with  a 
possible  relaxation  of  the  internal  os. 

Treatment. — Hot  douches  and  tampons  (see  p.  265)  may 
give  temporary  relief,  but  cannot  effect  a  cure  in  most  cases,  since 
they  do  no1  remove  the  cause  of  the  congestion.  Constipation 
should  be  overcome,  bad  habits  of  life  corrected,  and  an  effort  made 
to  tone  up  the  general  system.  Operative  treatment  consists  in 
dilatation  of  the  cervical  canal  and  removal  of  the  hypertrophied 
mucous  membrane.  Lacerations  should  be  repaired  and  malposi- 
tions corrected. 

Dilatation  of  the  Cervical  Canal. — Dilatation  of  the  cer- 
vical canal  is  the  most  important  of  minor  gynecological  opera- 
tions. This  can  be  performed  in  many  cases  under  a  local  anes- 
thetic, but  a  general  anesthetic  is  usually  more  satisfactory  for 
both  surgeon  and  patient. 

Dilatation  is  performed  for  the  relief  of  dysmenorrhea,  to  over- 
come sterility,  and  to  permit  of  curettage  or  other  operations 
within  the  cervix  or  uterus.  The  technique  is  as  follows :  The 
bowels  should  be  thoroughly  emptied  the  day  previous  by  laxa- 
tives and  an  enema.  The  hair  should  be  removed  by  shaving,  or 
better,  it  should  be  clipped  short  by  scissors,  thus  saving  the  patient 
from  a  good  deal  of  discomfort  when  the  shaved  hairs  begin  to 
grow  out.  The  external  parts  should  be  cleansed  with  soap  and 
hot  water,  and  the  vagina  douched  with  a  five  per  cent  solution 
of  creolin  or  some  other  antiseptic.  The  patient  is  put  in  the 
lithotomy  position,  and  the  posterior  wall  of  the  vagina  is  de- 
pressed with  a  weighted  speculum.  The  anterior  lip  of  the  cervix 
is  seized  with  a  tenaculum  forceps  and  drawn  down.  If  a  local 
anesthetic  is  employed,  three  drops  of  two  per  cent  solution  of 
cocain  should  be  injected  into  the  tissue  grasped  by  the  forceps, 
and  similar  injections  should  be  made  into  other  portions  of  the 
cervix  and  up  the  cervical  canal.  An  applicator  wrapped  with 
absorbent  cotton  saturated  with  a  ten  per  cent  solution  of  cocain 


CURETTAGE  267 

should  bu  passed  into  the  cervical  canal,  and  allowed  l<>  remain 
in  place  for  at  least  ten  minutes.  It  is  necessary  that  the  tip  of 
the  applicator  pass  the  internal  os,  as  otherwise  the  anesthesia  will 
not  be  complete. 

The  direction  of  the  cervical  canal  should  next  be  determined 
by  the  uterine  probe.  The  knowledge  thus  gained  is  of  impor- 
tance in  inserting  the  dilator.  The  dilator  should  be  fully  intro- 
duced before  its  blades  are  opened.  A  little  rotation  in  one  direc- 
tion or  the  other  facilitates  its  introduction.  Gentle  pressure  is 
then  made  upon  the  handles  for  ten  seconds.  The  pressure  is 
then  relaxed,  the  dilator  rotated  for  a  sixth  of  the  circle,  pressure 
again  exerted,  and  so  on.  In  this  manner,  by  brief  periods  of 
gentle  pressure  made  in  different  directions,  the  cervix  can  be 
sufficiently  dilated  to  permit  the  introduction  of  a  curette  or  other 
instrument  or  the  insertion  of  an  intra-uterine  stem  pessary.  The 
patient  should  remain  in  a  recumbent  position  for  at  least  twelve 
hours  after  this  operation. 

Curettage. — The  inner  lining  of  the  uterus  is  frequently 
scraped  out  as  a  means  of  treatment  in  cases  of  endometritis, 
and  also  as  a  means  of  removing  portions  of  placental  tissue 
remaining  after  abortion,  or  as  a  means  of  obtaining  tissue  for 
a  microscopical  examination  in  cases  of  suspected  cancer  of  the 
uterus,  etc. 

The  cervical  canal  is  first  to  be  dilated.  The  extent  and  direc- 
tion of  the  uterine  cavity  is  then  determined  by  the  uterine  probe, 
and  its  lining  scraped  from  the  fundus  to  the  cervix  by  a  sharp 
curette.  This  should  be  systematically  done,  as  otherwise  the 
scraping  is  apt  to  be  excessive  in  certain  portions  and  insufficient 
in  others.  The  detached  shreds  of  mucous  membrane  should  be 
thoroughly  washed  out  by  means  of  a  double  current  uterine  cath- 
eter. The  fluid  used  for  irrigation  should  be  hot  to  aid  in  con- 
trolling hemorrhage. 

The  patient  should  remain  in  bed  for  two  days  or  more,  accord- 
ing to  the  cause  for  which  the  curettage  is  performed.  A  custom 
which  some  operators  have  of  packing  the  cavity  of  the  uterus 
with  gauze  is  not  to  be  recommended  in  most  cases. 

If  the  scrapings  from  the  uterus  are  of  a  fungoid  or  exuberant 
character,  they  should  be  examined  microscopically,  since  they 
may  be  part  of  a  malignant  growth, 


268    AFFECTIONS   OF  THE    FEMALE   GENITO-URINARY   ORGANS 

Chancroid. — A  chancroid  may  occur  anywhere  about  the 
vaginal  orifice  or  its  immediate  vicinity.  If  it  is  so  situated  as 
to  lie  between  two  folds  of  skin,  the  lesion  is  often  reproduced  on 
the  opposing  surface.  For  this  reason  several  chancroids  of  vary- 
ing ages  and  sizes  are  often  found  in  the  same  patient.  The 
progress  of ,  the  disease  and  the  best  method  of  overcoming  it  are 
described  on  page  222.  It  is  desirable  to  keep  apart,  as  far  as 
possible,  the  folds  of  skin  so  as  to  limit  the  spread  of  the  infec- 
tion, hence  the  necessity  of  frequent  dressings  and  thorough  clean- 
liness. A  fold  of  gauze  laid  between  the  labia  of  the  right  and 
left  side,  and  held  in  place  by  the  perineal  strap  of  a  T-bandage, 
will  be  found  helpful. 


Fig.   131. — Multiple  Syphilitic  Tumors  of  the  Vulva. 


Syphilis. — A  chancre,  the  primary  lesion  of  syphilis,  may 
occur  at  any  exposed  portion  of  the  genital  organs  of  the  female, 


SYPHILIS 


269 


but  is  most  likely  to  be  found  upon  the  labia  minora  or  .some 
other  portion  of  the  delicate  skin  about  the  vaginal  orifice.  It 
may  be  single,  or  two  separate  lesions  may  coexist. 

The  primary  lesion  of  syphilis  is  apt  to  be  overlooked  in  the 
female.  The  surface  where  it  may  occur  is  much  greater  than  is 
that  of  the  male,  and  is  not  so  readily  examined.  Hence,  a  woman 
may  contract  syphilis  without  knowledge  of  the  fact.     This  ex- 


Fig.  132. — Syphilitic  Tumor  of  Thigh  near  the  Vulva.     Patient  a  negress  aged 

twenty-seven  years. 

plains  the  occurrence  of  later  lesions  of  the  disease  in  women  who 
deny  that  they  have  ever  had  syphilis,  and  whose  truthfulness  there 
is  often  no  reason  to  doubt. 

The  diagnosis  is  not  difficult  when  a  primary  lesion  is  found. 
Its  appearance  is  similar  to  that  of  a  primary  lesion  upon  the 
male  genitals. 

The  later  lesions  of  syphilis  are  not  infrequently  found  upon 
the  vulva.  The  tissues  are  prone  to  hypertrophy  under  the  in- 
fluence of  prolonged  irritation,  so  that  mucous  patches  develop 
strongly  and  condylomata  become  extensive,  later  syphilides  often 
assuming  a  multiple  papillomatous  character  (Fig.  131).  This  is 
the  more  usual  form,  although  single  tumors  also  occur  (Fig.  132), 
as  well  as  gummatous  ulceration. 

For  the  local  and  constitutional  treatment  of  syphilis,  see 
page  61. 


L>7()     AFFECTIONS    OF   THE    FEMALE   GENITO-UR1NARY    OKiJANS 

TUMORS 

Benign  Tumors. — The  benign  tumors  of  the  external  gen- 
itals, such  as  papilloma,  lipoma,  etc.,  require  no  espeeial  descrip- 
tion. The  treatment  is  the  same  as  when  similar  tumors  are  found 
elsewhere  in  the  body  (see  p.  185). 

Cyst  of  Bartholin's  Gland. — The  duct  of  Bartholin's  gland 
may  become  obstructed,  leading  to  a  distention  of  the  cavity  of  the 
gland  with  mucus.  This  gives  a  fluctuating,  rounded  tumor  at 
one  side  of  the  vaginal  orifice,  covered  by  normal  skin,  and  freely 
movable  on  the  deeper  parts.  It  should  be  dissected  out  through 
an  anteroposterior  incision  and  the  wound  closed  by  suture.  Or 
it  may  lie  cut  into  at  the  site  of  the  normal  opening  of  the  duct, 
and  drained  with  a  small  wick  of  silk  threads  until  the  artificial 
canal  thus  formed  has  become  lined  with  epithelium. 

Suppuration  of  Bartholin's  gland  is  described  on  page  283. 

Urethral  Caruncle. — This  is  a  vascular  tumor  of  the  meatus, 
made  up  of  connective  tissue  and  hypertrophied  papilla?  and  nu- 
merous dilated  blood-vessels.  It  is  covered  with  epithelium.  Such 
a  little  tumor  is  often  extremely  sensitive,  so  that  the  passage  of 
urine  or  the  slightest  touch  will  give  the  patient  great  pain. 

The  diagnosis  is  easily  made  if  the  labia  are  separated  and 
the  urethral  orifice  is  inspected.  There  will  then  be  noticed  a 
bright  red  tumor,  usually  entirely  outside  of  the  urethra,  but  some- 
times partly  within  it,  springing  from  the  mucous  membrane  by 
a  slender  pedicle.     Sometimes  more  than  one  such  tumor  exists. 

Treatment. — The  caruncle  should  be  thoroughly  removed 
after  anesthesia  has  been  produced  by  cocain.  On  account  of  the 
delicacy  of  the  overlying  epithelium,  the  application  of  a  bit  of 
absorbent  cotton  saturated  with  a  ten  per  cent  solution  of  cocain 
will  produce  a  complete  anesthesia  in  a  few  minutes.  The  mucous 
membrane  should  then  be  divided  around  the  pedicle,  dissected 
back  for  a  short  distance,  so  that  the  base  of  the  tumor  may  be 
divided  below  the  level  of  the  surrounding  mucous  membrane. 
The  vessels  should  be  ligated  with  fine  catgut  and  the  cuff  of 
mucous  membrane  sutured  with  fine  black  silk  so  as  completely  to 
cover  the  raw  area.     The  stitches  should  be  removed  in  four  days. 

Polyp  of  the  Cervix. — A  polyp  of  the  cervix  is  a  more  or 
less  rounded  tumor  composed  of  the  same  tissues  as  the  mucous 


CARCINOMA  271 

membrane  from  which  it  springs.  It  is  usually  distinctly  pedicled. 
It  generally  springs  from  the  mucous  membrane  of  the  cervical 
canal,  and  gives  rise  to  more  or  less  hemorrhage  and  pain.  As 
soon  as  it  appears  in  the  external  os  the  cause  of  the  hemorrhage 
is  evident.  Before  such  appearance  the  diagnosis  is  extremely 
difficult. 

Treatment. — The  pedicle  of  a  polyp  may  be  seized  with  for- 
ceps and  twisted  off.  If  the  point  from  which  the  polyp  springs 
is  not  distinctly  visible,  the  cervical  canal  should  first  be  dilated. 
On  account  of  the  possibility  that  polypoid  degeneration  of  the 
cervical  mucous  membrane  may  be  the  initial  stage  of  cancer  the 
operation  should  be  a  more  thorough  one  in  patients  who  have 
passed  their  fortieth  year.  A  general  anesthetic  should  then  be 
given,  the  cervix  fully  dilated  (p.  266)  and  the  base  of  each 
polyp,  or  the  mucous  membrane  from  which  the  polyps  spring, 
should  be  resected.  In  every  case  the  excised  tissue  should  be 
examined  microscopically. 

Carcinoma. — Carcinoma  of  the  vulva  begins  in  a  hard  swell- 
ing which  soon  ulcerates,  infiltrates,  and  affects  the  inguinal  lym- 
phatic glands.  In  other  words,  its  characteristics  are  those  of 
cancer  in  other  portions  of  the  body.  Owing  to  the  abundant  blood- 
supply  of  the  parts  its  growth  is  rapid.  Carcinoma  of  the  vagina 
as  a  primary  lesion  is  seldom  seen. 

Carcinoma  of  the  cervix  is  very  common  and  may  be  recog- 
nized both  by  palpation  and  inspection  as  an  indurated  swelling, 
with  rough  surface,  ulcerating,  and  having  a  putrid  odor.  There 
are,  however,  some  cases  of  erosion  of  the  cervix,  due  primarily 
to  laceration  and  secondarily  to  inflammatory  discharges  from  the 
uterus,  which  do  not  present  the  ordinary  appearances  of  cancer, 
but  which  upon  microscopical  examination  may  prove  to  be  malig- 
nant. In  suspicious  conditions  of  this  kind  it  is  important  to 
remove  a  section  of  the  ulcer  for  examination  by  a  competent 
pathologist.  This  can  be  easily  done  through  a  bivalve  or  tubular 
speculum,  the  pain  being  prevented  by  the  injection  of  a  few  drops 
of  a  two  per  cent  cocain  solution. 

Treatment. — A  malignant  tumor,  Avhether  beginning  exter- 
nally or  internally,  should  be  thoroughly  removed  if  possible.  If 
this  is  not  possible,  it  had  better  be  left  alone.  Those  who  advo- 
cate a  partial  removal  for  the  sake  of  getting  rid  of  foul  discharges 


272    AFFECTIONS   OF  THE  FEMALE   GENITOURINARY   ORGANS 

apparently  forget  that  ulcers  will  soon  form  again,  and  that  the ' 
patient  will,  sooner  or  later,  be  subjected  to  the  annoyance  of  an 
ulcerating  cancer,  unless  perchance  she  succumbs  to  the  so-called 
palliative  operation. 

£?o  11  uiii  inn  is  made  of  benign  tumors  of  the  body  of  the 
uterus,  or  other  abdominal  tumors,  since  the  consideration  of  such 
lesion  is  wholly  out  of  the  range  of  minor  surgery. 

ACQUIRED   DEFORMITIES 

Relaxation  of  the  Sphincter  of  the  Bladder. — Inconti- 
nence of  Urine. — Incontinence  of  urine  is  an  affection  of  old  age 
whose  treatment  is  most  unsatisfactory.  With  advancing  years  the 
sphincter  of  the  bladder  becomes  relaxed  until  a  woman  finds  it 
impossible  to  hold  her  water  as  long  as  she  has  been  accustomed 
to  do.  If  the  relaxation  of  the  sphincter  is  slight,  incontinence 
will  only  take  place  when  the  patient  coughs  or  otherwise  suddenly 
increases  the  pressure  upon  the  bladder.  In  more  marked  degrees 
of  the  trouble  there  is  a  constant  dripping  of  the  urine,  which 
keeps  the  patient  in  a  distressing  condition  not  only  for  herself, 
but  for  those  about  her.  This  weakness  is  often  increased  by  a 
local  condition  of  cystocele  or  prolapse  of  the  uterus.  The  possi- 
bility of  an  overfilled  and  overflowing  bladder  should  be  borne  in 
mind,  though  this  condition  is  less  common  in  women  than  in  men. 

Before  condemning  a  patient  to  the  constant  use  of  a  rubber 
urinal  the  urine  should  be  drawn  by  catheter  and  carefully  exam- 
ined so  that  its  amount  and  character  may  be  known.  One  should 
not  forget  the  possible  presence  within  the  bladder  or  urethra  of 
a  calculus  or  other  foreign  body,  or  a  polyp  or  other  tumor,  which 
may  be  the  cause  of  the  incontinence.  Attempts  should  be  made 
to  stimulate  the  sphincter  by  massage,  by  astringent  applications 
applied  in  the  urethra  or  vaginally,  by  cold  bathing,  and  by  elec- 
tricity. If  the  urine  is  found  to  be  neutral  or  alkaline,  benzoic 
acid  may  be  given,  or  the  benzoate  of  soda  ten  grains  a  day.  These 
drugs  are  irritating  to  the  stomach  and  should  therefore  be  given 
well  diluted  one  hour  after  meals.  More  often  the  urine  is  scanty 
or  too  acid,  so  that  an  abundance  of  drinking-water  and  alkaline 
diluents  should  be  prescribed.  Cystocele  or  prolapse  of  the  urethra 
or  uterus  should  be  relieved  by  a  pessary  or  cured  by  operation. 


RETENTION  OF  URINE  273 

Incontinence  of  Childhood. — Incontinence  of  urine  by  night  or 
by  day  is  not  uncommonly  seen  in  both  male  and  female  children, 
but  is  more  troublesome  in  girls  than  boys  (see  p.  2 20 ).  The 
attention  of  the  parents  should  be  directed  to  the  general  condi- 
tions which  favor  this  affection,  and  they  should  see  that  the  child 
sleeps  under  light  clothing  and  drinks  plenty  of  water  in  the  fore- 
noon and  but  little  or  nothing  for  some  hours  before  going  to  bed. 
It  is  often  of  advantage  to  arrange  the  mattress  so  that  the  hips 
are  slightly  higher  than  the  shoulders.  Cold  sponge  baths  night 
and  morning  are  also  of  assistance  in  overcoming  the  trouble.  In 
no  case  should  a  child  be  punished  for  a  weakness  it  cannot  avoid 
and  which  mortifies  it  extremely.  Among  the  various  drugs  which 
have  been  tried  with  more  or  less  success  belladonna  has  attained 
quite  a  reputation,  and  its  use  is  sometimes  followed  by  marked 
improvement.  The  urine  should  always  be  examined,  and  if  it 
is  unduly  acid,  alkaline  diluents  should  be  given.  In  obstinate 
cases  the  occasional  passage  of  a  cold  steel  sound  into  the  bladder 
will  stimulate  and  strengthen  the  sphincter  so  as  to  increase 
its  control.  Another  good  plan  is  to  give  the  child  a  measuring- 
glass,  and  encourage  it  to  retain  its  water  for  a  time  after  the 
first  inclination  to  urinate  is  noticed.  Such  restraint  should  not 
be  carried  too  far,  the  idea  being  a  gradual  strengthening  of  the 
muscles  through  systematic  exercise.  One  can  safely  predict 
that  the  lack  of  control  will  disappear  before  the  age  of  puberty 
is  reached. 

Retention  of  Urine.  —  Catheterization.  —  Retention  of 
urine  in  the  female  is  rarely  seen  except  after  an  operation  or  after 
childbearing.  It  is  due  sometimes  to  the  anesthetic,  sometimes  to 
the  changed  abdominal  pressure,  sometimes  to  the  operative  wound 
in  the  immediate  vicinity,  and  sometimes  simply  to  the  horizontal 
position.  There  are  women  who  are  unable  to  pass  water  lying 
down,  even  in  health. 

The  risk  of  catheterization  is  a  slight  one,  but  it  should  be 
avoided  when  possible.  It  is  better,  therefore,  to  postpone  it  until 
the  patient  has  made  some  ineffectual  attempts  to  empty  the  blad- 
der and  feels  pressure.  This  will  usually  mean  the  lapse  of  twelve 
or  sixteen  hours  after  an  operation  or  delivery.  After  many  gyne- 
cological operations  the  nature  of  the  operation  makes  it  unde- 
sirable to  allow  the  patient  to  urinate.     In  such  cases  the  bladder 


274    AFFECTIONS   OF  THE   FEMALE   GENITOURINARY   ORGANS 

should  be  emptied  regularly  by  catheter,  without  waiting  for  the 
patient's  sensal  ions. 

Catheterization,  which  is  so  simple  to  one  accustomed  to  its 
performance,  may  be  very  embarrassing  to  the  beginner,  especially 
if  the  nurse  announces  that  she  is  unable  to  find  the  urethra.  It  is 
therefore  worth  description. 

The  old  practise  of  passing  a  catheter  by  touch  has  no  place 
in  modern  aseptic  technique.  The  operator  should  sterilize  his 
hands  or  wear  sterile  gloves,  although  if  he  proceeds  properly  and 
a  glass  catheter  is  used  this  is  not  strictly  necessary,  for  he  will 
not  touch  any  part  of  the  catheter  which  enters  the  urethra.  The 
patient  Hexes  the  thighs  and  separates  the  knees  widely.  If  she 
is  lying  on  a  soft  bed,  a  pillow  should  be  placed  under  the  hips  to 
raise  the  vulva  well  above  the  level  of  the  bed.  With  the  thumb 
and  fingers  of  one  hand  the  operator  separates  the  anterior  part 
of  the  labia  minora  widely,  so  as  to  expose  the  vestibule.  With 
the  other  hand  he  wipes  the  vestibule  clean,  using  a  swab  of  ab- 
sorbent cotton  Avet  with  a  mild  antiseptic.  He  next  drops  the 
swab,  and  with  the  same  hand  takes  the  sterile  catheter,  near  its 
outer  end,  and  passes  it  gently  into  the  meatus.  The  catheter 
should  be  wet  with  saline  solution.  No  other  lubricant  is  needed, 
unless  the  catheter  is  unduly  large.  It  will  readily  follow  the 
urethra  to  the  bladder,  and  the  urine  at  once  streams  out.  When 
the  bladder  is  empty,  the  forefinger  is  placed  over  the  end  of  the 
catheter  in  order  to  prevent  the  escape  of  the  urine  as  it  is  with- 
drawn. If  a  rubber  catheter  is  used,  some  lubricant  is  generally 
necessary,  and  this  fact,  together  with  the  necessity  of  grasping 
the  catheter  near  the  tip,  makes  it  desirable  that  the  hands  of  the 
operator  shall  be  sterile.  The  irritation  which  follows  the  repeated 
use  of  a  glass  catheter  is  probably  due  to  the  fact  that  it  is  too 
large,  or  is  taken  from  an  irritating  solution  before  insertion,  or 
that  it  is  not  introduced  with  sufficient  gentleness. 

Prolapse  of  Urethra. — The  female  urethra  may  prolapse 
from  the  meatus  and  cause  much  discomfort,  or  even  sharp  pain. 
The  prolapse  may  be  complete,  that  is,  affecting  the  whole  surface 
of  the  mucous  membrane,  or  partial,  only  one  side  of  the  urethra 
being  affected.  Astringents  will  relieve  symptoms  in  mild  cases. 
In  severer  cases  cauterization,  both  by  heat  and  by  chemicals,  is 
often' tried,  but  usually  proves  unsatisfactory.     It  is  better  to  ex- 


PROLAPSE   OP   UTERUS  275 

eise  the  protruding  membrane  and  to  make  <m  exact  suture;  of  the 
cut  edges,  using  a  sharply  curved  needle  and  fine  black  silk.  If 
the  prolapse  is  extensive  the  whole  circle  of  mucous  membrane 
must  be  removed  and  the  wound  closed  with  exactness.  The  best 
method  of  suturing  is  by  a  number  of  interrupted  fine  black  silk 
stitches.  The  stitches  should  be  removed  in  four  or  five  days. 
This  operation  may  be  performed  under  cocain,  applied  on  a  cot- 
ton swab  directly  to  the  mucous  membrane.  A  four  per  cent  solu- 
tion should  be  used  for  the  purpose.  If  it  is  found  necessary 
to  inject  cocain,  the  area  of  mucous  membrane  to  be  removed 
should  be  marked  out  with  a  scalpel  before  the  injection  is  made. 
Otherwise  the  swelling  caused  by  the  injection  may  easily 
mislead  the  operator  as  to  the  amount  of  tissue  which  it  is  neces- 
sary to  excise. 

Another  method  of  operating  upon  prolapse  of  the  urethra  is 
to  make  an  incision  through  the  mucous  membrane  of  the  vagina 
a  little  way  above  the  orifice,  and  to  draw  out  through  this  in- 
cision so  much  of  the  urethral  mucous  membrane  as  is  considered 
to  be  superfluous.  This  is  cut  away  and  the  wounds  in  urethra 
and  vagina  are  sutured  separately,  the  former  at  least  with  ab- 
sorbable sutures. 

Old  Laceration  of  the  Perineum. — The  operation  to  re- 
store the  perineum  after  an  old  laceration  rests  on  the  same  prin- 
ciples as  that  to  close  a  fresh  wound  in  the  perineum.  The  surface 
of  the  cicatrized  area  must,  however,  be  dissected  away  before  the 
sutures  are  inserted,  and  either  removed  entirely  or  left  to  project 
as  a  fold  into  the  vagina.  These  operations  require  a  general  anes- 
thetic and  a  treatment  in  bed  of  not  less  than  ten  days  or  two 
weeks  in  order  to  secure  a  perfect  result.  Their  details  are  given 
in  every  gynecological  text-book.  An  operation  to  restore  the 
perineal  body  is  strongly  to  be  advised  as  a  preventive  of  future 
prolapse,  even  though  the  patient  has  no  present  symptoms. 

Prolapse  of  Uterus.- — The  uterus  may  sink  so  low  down  as 
to  present  itself  partially  or  wholly  outside  the  vaginal  orifice. 
This  condition  is  known  as  prolapse  of  the  uterus  and  is  usually 
found  in  women  who  have  borne  several  children.  For  the  occur- 
rence of  a  prolapse  three  things  are  necessary:  a  torn  perineum, 
greatly  relaxed  vaginal  walls,  and  a  lengthening  of  the  ligaments 

which  normally  hold  the  uterus  in  position.    In  addition,  the  whole 
20 


276    AFFECTIONS   OF  THE   FEMALE   GENITO-URINARY   ORGANS 

uterus,  or  a1  least  its  cervix,  is  usually  elongated  and  heavier  than 
normal. 

A  uterus  which  protrudes  partly  or  wholly  from  the  vagina 
causes  the  patient  discomfort,  prevents  her  from  walking  easily, 
and  often  makes  it  impossible  for  her  to  retain  urine  for  more 
than  an  hour  or  two  during  the  day.  Moreover  the  cervical  mu- 
cous membrane  being  unaccustomed  to  such  exposure,  often  ulcer- 
ates, so  that  a  foul  discharge  may  be  added  to  the  other  discom- 
forts of  the  sufferer. 

Treatment. — In  simple  cases  if  the  outlet  of  the  vagina  is 
not  too  much  widened,  a  retroversion  pessary  (Fig.  133)  may  cure 


Fig.   133.     Retroversion    Pessary   which  in    Many   Cases   will  keep  within 
the  Vagina  an  otherwise  Prolapsed  Uterus. 

the  patient  of  all  symptoms.  In  many  cases,  however,  the  pessary 
will  gradually  work  out  of  the  vagina  as  the  patient  walks  about. 
Special  supports  have  been  devised,  but  the  pressure  which  they 
make  upon  the  cervix  is  often  painful  and  may  cause  ulceration. 
The  usual  form  of  apparatus  consists  of  a  belt  to  which  is  at- 
tached posteriorly  a  spring.  The  spring  passes  between  the  legs 
of  the  patient  and  curves  upward  into  the  vagina.  At  its  ex- 
tremity is  a  ball  or  else  a  little  cup  which  fits  over  the  cervix. 
Such  apparatus  is  cumbersome,  hard  to  keep  clean,  and  should 
not  be  advised  whenever  an  operation  is  possible.  A  T-bandage 
will  sometimes  give  temporary  relief  if  the  uterus  is  crowded  well 


ADHESIONS   OF  THE   CLITORIS  277 

upward  by  several  large  cotton  tampons  pushed  into  the  vagina 
before  the  perineal  strap  of  the  bandage  is  secured. 

Several  operations  have  been  advised  for  prolapse  of  the  uterus. 
The  perineum  may  be  restored  by ,  suture.  The  caliber  of  the 
vagina  may  be  reduced  by  partial  .excision  and  suture  of  its  walls. 
A  hypertrophied  cervix  may  be  amputated,  the  round  ligaments 
may  be  shortened,  the  uterus  may  be  suspended  by  suture  to  the 
abdominal  wall,  or  finally  a  complete  hysterectomy  may  be  per- 
formed. This  last  operation,  while  entailing  a  somewhat  greater 
risk  than  the  others,  has  the  great  merit  of  not  being  followed  by 
recurrence. 

Fistula  of  the  Vagina,  etc. — Fistulas  between  the  ureters 
and  vagina,  or  bladder  and  vagina,  or  urethra  and  vagina,  or 
vagina  and  rectum  may  be  due  to  necrosis  of  the  septa  between 
these  various  tubes,  brought  about  by  long  continued  pressure  in 
childbirth,  or  as  the  result  of  an  accident,  or  as  the  result  of  in- 
flammation, or  they  may  be  due  to  malignant  ulceration. 

The  existence  of  a  fistula  is  made  known  by  the  passage  of  gas 
or  fecal  matter  from  the  rectum  into  the  vagina  or  bladder;  or 
of  urine  into  the  vagina  or  rectum.  Sometimes  a  probe  can  be 
passed  through  the  fistula  or  digital  examination  may  demonstrate 
its  presence. 

Fistula  from  a  benign  cause  may  be  cured  by  a  plastic  opera- 
tion, many  ingenious  forms  of  which  have  been  devised.  Suc- 
cess is  most  likely  to  follow  an  operation  in  which  the  defects 
in  the  two  mucous  surfaces  are  closed  in  such  a  manner  that  the 
suture  line  in  one  organ  is  not  exactly  opposite  the  suture  line  in 
the  other.  Of  course  no  attempt  should  be  made  to  close  a  fistula 
due  to  malignant  ulceration  unless  the  tumor  has  first  been  wholly 
removed. 

CONGENITAL   DEFORMITIES 

Adhesions  of  the  Clitoris. — Adhesions  of  the  prepuce  to 
the  clitoris  may  wall  in  sebaceous  material,  and  give  rise  to  irri- 
tation which  in  turn  may  induce  habits  of  masturbation.  This 
condition  should  therefore  be  sought  for  in  cases  of  unexplained 
reflex  irritation.  The  clitoris  is  exposed  by  drawing  outward  and 
upward  the  upper  ends  of  the  labia  minora,  at  the  same  time 
pushing  the  fingers  backward  against  the  symphysis,  in  order  to 


278    AFFECTIONS   OF   Tin;   FEMALE   GEXITO  l  UNARY   ORGANS 

make  the  head  of  the  clitoris  projeel  forward.  The  technic  is 
similar  to  that  performed  to  uncover  the  head  of  the  penis  of  a 
fat  squirming  baby.     If  adhesions  arc  present,  this  manipulation 

will  make  them  appear. 

Treatment. — The  parts  should  he  saturated  with  twenty  per 
cent  cocain  solution  tor  ten  minutes.  The  prepuce  can  then  he 
withdrawn  without  pain,  and  while  tension  is  made  upon  it,  a 
small  flat  probe  should  he  passed  around  the  head  of  the  elitoris 
to  break  up  all  adhesions.  The  raw  surfaces  should  be  smeared 
with  e<»ld  cream.  The  parts  should  he  washed  daily  with  warm 
water,  and  this  retraction  and  anointing  should  he  repeated 
every  second  day  for  a  week  or  two  to  prevent  the  reformation  of 
adhesions.  If  there  is  a  redundancy  of  prepuce,  it  may  be  ex- 
cised and  the  wound  sutured  with  fine  black  silk.  This  is  a 
material  aid  in  breaking  up  the  habit  of  masturbation,  as  the 
practise  is  interrupted  for  a  few  days  by  the  soreness  and  the 
changed  sensation  assists  the  child  in  not  resuming  the  habit. 

Imperforate  Hymen.  — The  hymen  may  be  without  an 
opening.  As  a  result  of  this  malformation,  when  menstruation 
first  occurs,  the  escape  of  blood  from  the  vagina  may  be  pre- 
vented. Such  a  patient  will  have  the  usual  subjective  symptoms 
of  menstruation  without  any  flow  of  blood.  Under  these  circum- 
stances a  careful  examination  will  reveal  a  cystic  distention  of 
the  hymen,  and  the  dark  blue  color  of  the  concealed  fluid  will 
at  once  explain  matters.  An  incision  should  be  made  and  the 
blood  and  blood  clots  allowed  to  escape. 

In  other  cases  the  lack  of  development  may  extend  higher  up 
and  the  vagina  be  partly  or  wholly  absent  or  the  cervix  be  with- 
out an  opening. 

Stenosis  of  the  Cervix. — An  imperfect  development  of 
the  cervical  canal  is  one  of  the  commonest  causes  of  dysmenor- 
rhea. The  opening  may  he  so  small  that  it  will  only  admit  the 
passage  of  a  small  probe.  This  may  be  sufficient  for  the  escape 
of  fluid  blood,  but  not  for  the  easy  passage  of  even  a  small  blood 
clot.  The  result  is  a  contraction  of  the  uterus,  continued  until 
the  cervix  is  sufficiently  dilated  to  permit  the  clot  to  escape.  The 
pain  thus  caused  may  he  very  severe,  even  causing  unconscious- 
ness. The  stenosis  may  disappear  with  repeated  menstruation 
or  with   the   sexual   stimulus   of  marriage,  but  such   is  not   al- 


STENOSIS    OK   THE   CERVIX 


279 


ways   the   case.      It  is   permanently   overcome   in   most   cases   by 
pregnancy. 

Treatment. — It  is  surprising  how  many  young  women  are 
allowed  to  suffer  unnecessary  pain  during  the  first  day  or  two 
of  menstruation  year  after  year,  when  a  slight  operation  and 
a  little  subsequent  treatment  would  avoid  it.  The  indication 
under  such  circumstances  for  dilatation  of  the  cervical  canal  is 
clear  enough.  The  technic  of  its  performance  is  given  on  page 
266.  In  these  cases  it  should 
not  he  followed  by  curettage,  as 
the  uterine  mucous  membrane  is 
in  no  wise  at  fault.  When  the 
cervix  has  been  dilated,  a  hard 
rubber  plug  (Fig.  134)  should 
be  inserted  and  left  in  place 
for  two  or  three  months.  This 
should  be  about  22  or  25  French 
catheter  scale,  and  should  be 
long  enough  to  reach  through 
the  internal  os,  as  otherwise  it 
may  slip  out  of  place.  These 
plugs  are  sometimes  made  with 
a  lateral  groove  to  permit  the 
escape  of  blood  during  menstruation.  This  is  unnecessary,  as 
the  blood  escapes  around  the  plug  and  the  groove  makes  a  lodging- 
place  for  blood  and  mucus.  If  symptoms  of  obstruction  recur 
in  a  few  months  after  the  removal  of  the  plug,  it  should  be 
reinserted. 

This  operation  can  be  painlessly  performed  with  cocain ;  but 
in  many  cases  the  sensibilities  of  the  patient  render  a  general  anes- 
thetic desirable. 

A  hard  rubber  plug  of  this  shape  acts  as  a  valve  and  will  pre- 
vent the  entrance  of  seminal  fluid  into  the  uterus.  The  dilata- 
tion of  the  cervical  canal  which  follows  its  use  is  favorable  to 
pregnancy  after  the  plug  has  been  removed. 


Fig.  134. —  Hard  Rubber  Plugs  for 
the  Cure  of  Stenosis  of  the  Cer- 
vix. 


SECTION  V 

AFFECTIONS   OF   THE   ANUS   AND 
RECTUM 


CHAPTEE    XI 

INJURIES    AND    INFLAMMATIONS    OF    THE    ANUS 
AND    RECTUM 

METHODS   OF   EXAMINATION 

Examination  of  the  Patient. — There  are  two  positions  of 
tin-  patient  which  are  satisfactory  for  an  office  examination  of  the 
anus  and  lower  portion  of  the  rectum.  If  the  patient  is  a  man 
he  may  stand  with  his  back  toward  the  light  and  bend  well  for- 
ward, resting  his  hands  upon  the  seat  of  a  chair.  This  position 
affords  the  examiner  an  excellent  view  of  the  region  of  the  anus, 
and  it  also  facilitates  digital  examination,  especially  of  the  ante- 
rior portion  of  the  rectum. 

The  other  position,  which  is  to  be  employed  with  women,  and 
which  is  preferred  by  some  surgeons  in  all  cases,  is  the  lateral 
recumbent  position,  with  both  thighs  flexed  upon  the  abdomen. 
The  thigh  which  is  uppermost  should  be  flexed  a  little  farther  than 
the  other. 

Examination  begins  with  inspection  not  merely  of  the  skin, 
but  also  of  the  anal  canal.  The  folds  of  the  anus  should  be  sepa- 
rated and  the  anal  mucous  membrane  should  be  drawn  out  a 
little  at  a  time,  and  the  patient  should  also  be  directed  to  strain, 
so  that  the  examiner  may  see  how  much  venous  dilatation  is 
thereby  produced. 

Palpation  is  chiefly  of  service  to  reveal  the  extent  of  inflam- 
matory exudation,  and  to  show  the  existence  of  a  hidden  fistula. 

If  a  sinus  exists,  the  passage  of  a  probe  will  sometimes  reveal 

its  direction  and   extent.      This   is  usually  a  painful  method  of 

examination,    and    the  knowledge  thereby  gained   is   not   always 

very  extensive. 
280 


EXAMINATION   OF   THE   PATIENT  281 

Digital  examination  is  of  the  greatest  importance.  A  rubber 
glove  may  be  worn  or  the  finger  may  be  covered  with  ;i  finger  cot. 
The  latter  is  thinner  than  a  glove,  and  so  does  not  dull  the  sensa 
tion  to  the  same  degree,  but  it  does  not  protect  the  base  of  the 
finger  from  contamination.  Even  by  the  thinnest  finger  cot  the 
tactile  sense  is  somewhat  obscured,  as  any  one  may  prove  for 
himself  by  making  tests  upon  various  rough  objects. 

The  finger  should  be  well  oiled,  preferably  with  a  heavy  lubri- 
cant, such  as  vaseline,  or  one  of  the  preparations  from  Irish  moss. 
It  should  be  inserted  slowly  and  rotated  during  the  insertion,  in 
order  to  clear  the  folds  of  mucous  membrane.  When  the  fin^r 
has  been  fully  inserted,  all  of  the  rectum  within  reach  should  be 
systematically  palpated  with  the  palmar  surface  of  the  finger.  It 
is  possible  to  recognize  in  this  way  a  wound,  impaction  of  feces, 
a  foreign  body,  a  fissure,  an  abscess,  a  fistula,  inflammatory  thick- 
ening of  the  rectal  wall,  a  stricture,  a  benign  or  malignant  tumor, 
or  a  hemorrhoid. 

One  can  usually  obtain  far  more  knowledge  from  a  digital  ex- 
amination made  when  the  rectum  is  empty;  but  since  it  may  be 
desirable  to  know  what  is  the  usual  condition  of  the  rectum,  it  is 
just  as  well  to  make  an  examination  when  the  patient  first  presents 
himself,  and  if  the  rectum  is  found  to  be  full  of  feces,  the  bowel 
should  be  thoroughly  emptied  by  a  cathartic  or  enema,  and  a  sec- 
ond examination  made. 

There  is  one  other  position  in  which  a  patient  should  some- 
times be  examined:  namely,  a  squatting  position.  In  this  posi- 
tion, and  especially  if  the  patient  strains,  the  examiner's  finger 
will  reach  portions  of  the  rectum  which  are  inacessible  in  other 
positions.  Furthermore,  if  the  normal  planes  of  tissue  have  been 
in  any  way  weakened,  this  fact  will  be  manifest  in  this  position 
as  in  no  other.  This  is  equally  true  of  excessive  valvular  forma- 
tion within  the  rectum,  and  of  hernial  protrusions  outside  of  it. 

Inspection  of  the  interior  of  the  rectum  by  means  of  a  procto- 
scope will  often  yield  valuable  knowledge  without  an  anesthetic. 
The  instrument  used  should  be  short,  not  more  than  three  or  four 
inches  in  length,  and  preferably  an  inch  or  more  in  diameter 
(Fig.  135).  If  a  tube  of  much  smaller  caliber  is  employed,  the 
mucous  membrane  will  lie  in  such  deep  folds  that  a  great  deal 
of  it  will  escape  observation.     If  the  hips  are  higher  than  the 


_>S_'  INJURIES   OF   THE   AM  S   AND    RECTUM 

abdomen,  and  the  clothing  is  all  loosened,  the  intestines  will  fall 
away  from  the  pelvis,  and  the  lower  portions  of  the  rectum  will 
gape  open  and  till  with  air.  This  facilitates  very  much  the  inspec- 
tion  through   the   proctoscope.     The   knee-chest  position  is  espe- 


Fig.   135. — A  Suitable  Rectal  Speculum  for  Office  Examinations. 

cially  good  for  this  purpose.  In  many  patients,  even  though  no 
inflammation  be  present,  the  passage  of  the  proctoscope  excites  a 
painful  spasm  of  the  sphincter  ani.  This  method  of  examination 
is  not  suited  to  cases  in  which  acute  inflammation  is  present. 

Stretching-  of  the  Sphincter  Ani. — It  may  be  necessary  to 
stretch  the  sphincter  ani  for  purposes  of  examination,  or  as  a 
means  of  treatment,  or  as  a  preliminary  to  treatment.  It  is  best 
performed  in  the  following  manner:  The  patient  should  be  thor- 
oughly anesthetized  with  gas,  ether,  or  chloroform,  and  should 
be  in  either  the  dorsal  position,  the  legs  being  held  by  a  crutch  or 


STRETCHING   OF   THE   SPHINCTER  ANI 


283 


an  assistant;  or  else  lie  should  lie  in  the  lateral  position,  with 
the  knees  well  drawn  up  toward  the  chest.  The  anal  region  should 
be  cleansed  with  soap  and  warm  water.  The  two  forefingers  of  the 
operator  should  be  lubricated  and  pushed  well  up  into  the  rectum. 
Their  palmar  surfaces  should  be  directed  away  from  each  other. 
Steady  pressure  should  next  be  made  to  separate  the  two  fingers, 
and  this  pressure  should  be  exerted  in  different  directions  antero- 
posteriorly,  laterally,  and  obliquely.  As  the  sphincter  gives  way, 
a  third  finger  should  be  inserted,  and  then  a  fourth.  The  sphinc- 
ter cannot  be  considered  dilated  unless  the  two  fingers  of  each 
hand  may  be  pressed  against  the  ischia  on  either  side  without  the 
use  of  much  force.  Some  oper- 
ators prefer  to  stretch  the  sphinc- 
ter with  the  thumbs.  Digital  dila- 
tation in  the  manner  described  is 
safer  and  otherwise  more  satisfac- 
tory than  dilatation  by  means  of 
any  instrument.  The  mucous 
membrane  at  the  anal  margin  will 
usually  be  cracked  here  and  there, 
but  these  superficial  breaks  in  the 
mucous  membrane  require  no 
treatment  other  than  that  of 
cleanliness.  The  patient  may  get 
up  and  go  about  as  soon  as  the 
dizziness  caused  by  the  anesthetic 
has  passed  off. 

Stretching  of  the  sphincter 
often  causes  some  hemorrhage  in 
the  deep  tissues,  so  that  on  the  fol- 
lowing day  the  anus  may  be  sur- 
rounded by  a  black  and  blue  zone. 
This  will  disappear  without  treat- 
ment in  a  few  days. 

Stretching  the  sphincter  great- 
ly facilitates  inspection  of  the  rec- 
tum through  a  speculum.     A  bi- 
valve instrument    (Tig.   136)   can  then  be  employed  and  turned 
in  different  directions,  so  as  to  give  a  view  of  the  whole  canal. 


Fig.  136. — Bivalve  Rectal  Specu- 
lum. A  good  instrument  to  em- 
ploy after  the  sphincter  has  been 
stretched. 


284  INJURIES    or  THE  ANUS    AND   RECTUM 

INJURIES 

Wounds  of  the  anal  region  are  for  the  most  part  due  to 
falls  upon  sharp  objects;  or  llicv  may  be  the  result  of  violence 
inflicted  by  the  patient  or  others.  Slight  wounds  may  follow  the 
passage  through  the  anal  canal  of  some  sharp  object,  such  as  a 
splinter  or  fish  bone  which  projects  from  a  fecal  mass.  In  making 
the  examination  of  a  patient  who  has  fallen  upon  a  sharp  objed 
it  is  well  to  remember  that  a  small  foreign  body  may  pass  the  anus 
and  penetrate  the  wall  of  the  rectum  without  leaving  any  external 
sign  of  injury;  hence  the  importance  of  a  speculum  examination 
in  such  cases. 

Treatment. — The  first  indication  for  treatment  is  the  control 
of  hemorrhage.  External  hemorrhage  will  he  noticed  at  once,  and 
may  be  controlled  by  pressure  or  styptics,  such  as  adrenalin  or  per- 
oxid  of  hydrogen.  If  a  vessel  is  lacerated  above  the  sphincter,- 
hemorrhage  may  take  place  into  the  rectum  and  not  make  itself 
manifest  for  some  time.  Under  such  circumstances  the  pas- 
sage of  a  speculum  or  of  a  rectal  catheter  or  any  other  tube 
will  show  at  once  whether  the  bleeding  is  continuous.  If 
so,  the  sphincter  should  be  dilated  and  the  ruptured  artery 
ligated. 

.If  the  wound  is  so  placed  as  to  be  pulled  upon  by  the  dila- 
tion and  contraction  of  the  sphincter,  which  takes  place  during 
defecation,  it  is  better  to  stretch  the  sphincter  fully,  so  as  to  insure 
rest  to  the  wound.  This  not  only  adds  to  the  patient's  comfort, 
but  hastens  repair. 

Wounds  in. this  vicinity  should  be  treated  like  all  other  wounds 
by  thorough  cleansing,  and  if  of  sufficient  size,  by  a  careful  suture. 
Although  exposed  to  contamination,  wounds  of  this  region  heal 
promptly  in  many  cases,  thanks  to  the  free  blood-supply.  Fine 
black  silk  is  the  best  suture  material  to  employ  for  the  portion 
of  the  wound  which  is  external.  The  portion  of  the  wound  which 
is  so  situated  that  the  stitches  cannot  be  easily  removed  should 
be  sutured  with  plain  catgut  or  a  fine  ten  day  chromicized  gut. 
If  the  wall  of  the  rectum  is  wounded,  the  possibility  of  peritoneal 
involvement  should  be  borne  in  mind. 

Hemorrhage. — Hemorrhage  into  the  rectum  or  from  the  anus 
may  be  due  to  a  gross  injury  or  to  a  small  ulceration  occurring 


HEMORRHAGE  285 

in  connection  with  hemorrhoids,  prolapse,  or  tumors.      Further 
more,  the  hemorrhage  following  operation  upon  the  rectum,  while 
not  strictly  speaking  within  the  domain  of  minor  surgery,  often 
shows  itself  after  the  operator  is  out  of  reach,  and  its  treatment 
should  therefore  he  understood  by  every  practitioner. 

Tkeatment. — As  stated  above,  bleeding  from  an  external 
wound  or  ulcer  is  readily  controlled  by  pressure,  ligation,  or 
styptics,  such  as  peroxid  of  hydrogen  or  adrenalin.  If  there  is 
capillary  oozing,  as  from  a  prolapsed  hemorrhoid,  the  appli- 
cations of  swabs  wrung  out  of  very  hot  water  will  usually  con- 
trol it. 

Hemorrhage  from  a  vessel  so  far  up  that  it  is  not  included  in 
the  sphincter  ani  is  far  more  dangerous,  and  demands  prompt  and 
thorough  treatment.  When  this  follows  operation  within  a  few 
hours  it  either  comes  from  a  vessel  which  has  not  been  ligated 
or  from  which  the  ligature  has  slipped.  The  usual  symptoms  are 
these :  The  patient  will  complain  of  some  pain  in  the  rectum,  and 
state  that  he  feels  that  his  bowels  are  going  to  move.  The  nurse 
or  doctor  will  probably  tell  him  that  he  is  mistaken,  and  that  his 
feelings  are  due  to  the  operation  or  to  the  presence  of  gauze  in 
the  rectum,  if  a  plug  of  this  material  has  been  inserted.  In  a 
few  minutes  the  patient  will  again  insist  that  his  bowels  are  going 
to  move,  and  the  passage  of  four  or  more  ounces  of  fluid  blood 
will  prove  the  correctness  of  his  statement.  Under  such  circum- 
stances any  gauze  should  be  removed  from  the  rectum,  the  bowel 
irrigated  with  as  hot  a  sterile  saline  solution  as  the  patient  can 
bear,  and  if  the  flow  of  blood  continues,  an  anesthetic  should  be 
given,  the  sphincter  dilated,  a  bivalve  speculum  inserted,  and  the 
bleeding  point  exposed  and  ligated. 

This  accident  is  peculiarly  liable  to  follow  operations  upon 
internal  hemorrhoids,  performed  under  cocain,  with  incomplete 
or  no  dilatation  of  the  sphincter.  The  cocain,  or  mixture  of 
cocain  and  adrenalin  deceives  the  operator  in  regard  to  the 
amount  of  bleeding  possible  from  the  cut  surface,  and  when 
the  astringent  action  of  these  drugs  passes  off  the  real  mischief 
begins. 

There  is  also  the  so  called  secondary  hemorrhage,  due  to  the 
opening  of  an  artery  by  the  sloughing  away  of  the  ligature  which 
has  been  put  around  it.     This  is  most  likely  to  follow  when  masses 


2S6  INJURIES  OF  THE  ANUS  AND    RECTUM 

of  other  tissue  are  included  with  the  artery  in  the  ligature,  a 
method  <>f  tiH'hnie  advised  by  some  operators  upon  hemorrhoids. 
Such  secondary  hemorrhage  may  therefore  occur  five  or  seven  or 
even  ten  days  after  the  operation.  Its  symptoms  and  treatment 
are  the  same  as  those  given  above. 

Foreign  Bodies  and  Impacted  Feces. — Foreign  bodies  are 
frequently  inserted  into  the  rectum,  either  for  the  purpose  of  sex- 
ual excitement  or  to  assist  in  defecation  or  in  urination.  Insane 
persons  sometimes  pass  foreign  bodies  into  the  rectum.  The  rec- 
tum, especially  in  old  people,  is  tolerant  of  foreign  bodies,  owing 
no  doubt  to  the  fact  that  in  civilized  life  many  persons  habitually 
allow  fecal  matter  to  remain  in  the  rectum  for  hours  or  possibly 
for  days.  Such  hardened  balls  of  feces  may  become  so  firm  that 
they  cannot  be  evacuated  and  require  the  treatment  of  foreign 
bodies. 

Treatment. — The  extraction  of  a  foreign  body  is  a  simple 
process  after  the  sphincter  has  been  dilated  (p.  282).  Smaller 
objects  may  be  extracted  with  the  finger  or  a  dressing  forceps 
guided  by  the  finger.  In  this  way  the  patient  may  be  saved  the 
annoyance  of  a  general  anesthetic.  A  hardened  ball  of  feces  can 
usually  be  broken  up  digitally  and  extracted  piecemeal  by  the 
finger  or  by  dressing  forceps  or  washed  out  by  repeated  injections, 
after  it  has  been  broken  up.  The  rectum  should  have  rest  for  a 
few  days  to  recover  its  tone  and  to  allow  for  healing  of  the  abra- 
sions which  may  be  produced.  Hot  external  applications  are  grate- 
ful to  the  patient. 

INFLAMMATIONS 

Intertrigo. — Intertrigo,  or  chafing  of  the  skin,  may  occur 
<>n  any  portion  of  the  body  where  two  skin  surfaces  come  into  con 
fact.  It  is  especially  troublesome  between  the  folds  of  the  but- 
tocks. It  may  be  due  to  a  lack  of  cleanliness,  to  irritating  dis- 
charges, or  to  an  unusual  amount  of  exercise.  When  due  to  the 
last  named  cause,  it  may  be  so  severe  that  blisters  develop.  When 
due  to  irritating  discharges,  if  it  is  long  continued  it  may  pass 
into  eczema. 

The  essentials  of  treatment  are  cleanliness,  separation  of  the 
folds  of  the  skin  by  gauze  or  cotton  saturated  with  a  cooling 
lotion,  or  the  reduction  of  friction  between  opposing  surfaces  by 


PRURITUS   ANI  287 

means  of  a  simple  ointment,  such  as  cold  cream  or  a  dusting  pow- 
der. If  unusual  exercise  is  to  be  taken,  the  chafing  can  be  pre- 
vented in  many  instances  by  a  preliminary  application  of  cold 
cream  to  the  opposed  surfaces. 

Pruritus  Ani. — This  name  is  given  to  the  troublesome  itch- 
ing about  the  anus  which  may  occur  at  any  age,  but  is  espe- 
cially common  among  elderly  persons.  In  children  it  is  often 
due  to  pinworms.  In  adults  it  may  be  caused  by  an  irritating 
discharge  from  the  rectum  or  vagina,  or  it  may  be  due  to  hemor- 
rhoids or  to  fissures.  In  every  case  the  affected  part  should  be 
examined  in  a  good  light.  The  folds  of  the  anus  should  be  sepa- 
rated in  order  to  expose  hidden  fissures.  If  nothing  is  found 
externally  a  speculum  should  be  passed,  and  the  mucous  mem- 
brane of  the  rectum  examined.  Digital  examination  should  also 
be  made,  in  order  to  determine  the  presence  of  hemorrhoids 
and  the  amount  of  contraction  of  the  sphincter.  The  stools 
should  also  be  examined,  since  they  may  be  of  an  irritating 
character. 

Treatment. — If  any  cause  for  the  pruritus  is  found,  it 
should  be  removed.  If  there  are  pinworms,  a  pint  of  water  con- 
taining an  ounce  of  the  fluid  extract  of  quassia  should  be  in- 
jected into  the  rectum,  and  kept  there  fifteen  minutes.  In  a 
child  a  less  quantity  will  suffice.  This  treatment  should  be  re- 
peated on  two  or  three  succeeding  days.  If  a  fissure  or  hemor- 
rhoid or  ulcer  of  the  rectum  or  other  obvious  cause  of  pruritus 
exists,  suitable  treatment  should  be  instituted. 

In  all  cases  errors  in  diet  should  be  avoided.  The  patient 
should. give  up  alcohol,  tobacco,  and  coffee.  Constipation  should 
be  corrected.  The  rectum  should  be  regularly  emptied,  and  kept 
empty,  by  saline  laxatives  or  enemata.  If  the  sphincter  is  tight, 
it  should  be  stretched.  This  may  be  performed  by  the  doctor's 
fingers,  the  patient  having  been  rendered  unconscious  by  laughing 
gas ;  or  a  gradual  dilatation  may  be  preferred.  The  latter  is  best 
performed  by  the  patient,  who  every  night  upon  retiring  should 
insert  a  hard  rubber  rectal  dilator,  and  leave  it  in  place  for  fif- 
teen to  thirty  minutes.  These  dilators  come  in  three  sizes.  After 
a  few  nights  the  patient  will  be  able  to  pass  the  largest  size  with- 
out pain.  When  the  dilator  has  been  removed,  the  patient  should 
liberally  apply  the  following  ointment: 


2SS             INFLAMMATIONS  OF  THE  ANUS  AND  RECTUM 
I>   Camphorii! gr.  4 ; 


Menthol    gr. 


-> 


Ac.  earbol gr.  30 

Ac.  boric gr.  10 

Calomel    gr.  10 

Ung.  zinc,  ox q.  s.  ad.  oz.  1. 

M. 

This  treatment  should  be  continued  every  night  for  a  month, 
or  until  the  sphincter  is  looser  than  normal. 

Some  patients  are  relieved  by  the  application  of  hot  or  cold 
water  two  or  three  times  a  day.  This  may  be  followed  by  an 
application  of  a  powder  composed  of  one  part  each  of  camphor 
and  chloral  rubbed  together  and  added  to  thirty  parts  of  starch. 

The  itching  may  be  stopped  temporarily  by  the  application 
of  a  solution  containing  ten  per  cent  or  less  of  resorcin;  or  of 
one  containing  five  per  cent  or  less  of  carbolic  acid.  Another 
method  of  using  carbolic  acid  is  to  apply  it  pure,  and  wash  it  off 
almost  immediately  with  alcohol.  This  will  sometimes  stop  the 
itching  for  several  days.  The  surface  may  be  painted  with  a 
mixture  of  equal  parts  of  the  tincture  of  iodine  and  the  fluid 
extract  of  hamamelis. 

If  the  skin  is  excoriated  or  inflamed  by  reason  of  scratching, 
it  is  a  good  plan  to  keep  a  fold  of  gauze  between  the  nates,  wet 
with  some  cooling  lotion  or  smeared  with  vaseline  containing  20 
grains  of  carbolic  acid  and  10  grains  of  cocain  to  the  ounce. 

Proctitis. — Inflammation  of  the  rectum,  or  proctitis,  may  be 
either  acute  or  chronic,  and  the  latter  is  again  divided  into  atrophic 
and  hypertrophic  proctitis. 

The  acute  form  of  the  disease  may  be  due  to  mechanical  in- 
jury or  to  a  sudden  change  in  temperature,  as  when  a  person  after 
exercise  sits  upon  cold,  damp  ground;  or  to  chemical  irritation 
following  the  ingestion  of  improper  food  or  to  intestinal  fermenta- 
tion or  to  bacterial  infection,  either  from  the  feces  or  from 
objects  introduced  into  the  rectum. 

The  symptoms  of  heat,  fulness,  and  pain  are  common  to 
catarrhal  inflammation  of  all  mucous  membranes,  and  in  addi- 
tion there  is  a  constant  or  oft  repeated  desire  for  evacuation. 
Usually  the  movements  are  fluid  or  mixed  with  mucus  and  blood. 


FISSURE  289 

Treatment. — The  bowels  should  be  irrigated  for  cleansing 
purposes,  and  this  should  he  followed  by  a  continuous  irrigation 
for  ten  or  fifteen  minutes,  with  either  hot  or  cold  normal  saline 
solution.  This  may  he  carried  out  through  a  specially  devised 
double  current  rectal  tube,  or,  as  is  more  comfortable  to  many 
patients,  two  small  soft  rubber  catheters  may  be  employed,  one 
for  the  inflow  and  one  for  the  outflow.  After  the  irrigation,  a 
suppository  of  opium  and  iodoform  should  be  inserted,  or  one 
containing  iodoform,  and  tannic  acid,  for  in  these  cases  opium  and 
morphine  must  be  used  with  caution.  At  least  twice  a  day  the 
saline  irrigation  should  be  followed  by  a  stimulating  enema.  Vari- 
ous solutions  have  been  recommended  for  this  purpose,  such  as 
nitrate  of  silver,  1:  3,000;  boric  acid,  3  per  cent;  acetate  of  lead, 
1:  500;  fluid  extract  of  hydrastis  an  ounce  in  two  quarts  of  hot 
water,  etc. 

In  chronic  proctitis  similar  measures  are  to  be  employed. 
Usually  the  cause  is  a  long  continued  one,  and  it  may  not  be  possi- 
ble to  remove  it  entirely.  At  least  one  may  attend  to  the  diet  and 
keep  the  stools,  soft  with  castor  oil  or  one  of  the  milder  salines. 
The  astringent  enemas  may  be  somewhat  stronger  than  in  acute 
proctitis,  but  it  is  better  to  begin  with  the  milder  solutions  and 
to  increase  their  strength  gradually  as  the  effect  is  evident.  Per- 
sistent ulcers  may  be  sprayed  or  swabbed  with  still  stronger  appli- 
cations. 

Fissure. — Fissure  of  the  anus  is  a  crack  in  the  mucous  mem- 
brane at  the  orifice  of  the  anal  canal,  and  situated  generally  near 
the  anterior  or  posterior  commissure.  It  is  due,  in  most  cases  at 
least,  to  the  scratching  of  the  mucous  membrane  by  the  passage 
of  hard  fecal  masses  and  infection  of  the  small  wound.  The  espe- 
cial development  of  the  sinuses  of  Morgagni  near  the  commissures 
is  thought  to  determine  the  frequent  development  of  fissures  in 
these  situations. 

In  its  early  stages  a  fissure  gives  the  patient  only  a  little  dis- 
comfort. There  is  a  stinging  pain  as  the  fecal  mass  passes  the 
fissure,  and  a  drop  or  two  of  blood  may  be  found  either  on  the 
expelled  feces  or  on  the  paper  used  to  cleanse  the  anus.  There 
is  also  a  feeling  of  heat  or  a  throbbing  dull  pain  for  a  few  min- 
utes. As  the  fissure  becomes  deeper  and  more  indurated  these 
slight  symptoms  are  greatly  increased.     In  an  extreme  case  the 


290  INFLAMMATIONS  OF  THE  ANUS  AND  RECTI' M 

thought  of  defecation  tills  the  patient  with  terror,  and  the  entrance 
of  the  focal  mass  into  the  anal  canal  excites  a  violent  spasm  of  the 
sphincter,  which  makes  the  act  of  defecation  tenfold  more  diffi- 
cult. The  pain  thus  caused  may  last  for  hours  and  seriously 
interfere  with  the  patient's  daily  life. 

Tkkatmknt. — The  treatment  of  fissure  that  can  he  carried 
out  by  the  patient  is  most  important,  since  under  its  influence 
many  tissures  of  slight  degree  will  permanently  heal.  The  bowels 
should  he  made  regular  and  the  stools  semisolid  by  changes  in 
diet  and  such  laxatives  as  are  found  to  agree  best  with  the  par- 
ticular patient.  Straining  at  stool  is  to  "be  avoided.  Lubrication 
of  the  anal  canal  before  defecation  will  do  much  to  prevent  the 
formation  of  a  fissure  and  to  favor  the  healing  of  one  already 
existing.  The  patient  can  accomplish  this  by  injecting  a  small 
syringeful  of  oil  or  by  passing  his  greased  finger  into  the  anus. 
After  defecation  the  anus  should  be  washed,  not  rubbed  with  a 
dry  and  perhaps  stiff  paper.  If  the  patient  will  not  take  this 
trouble  he  can  at  least  expectorate  upon  the  paper  before  apply- 
ing it.  The  alkaline  viscid  saliva  is  non-irritating  to  the  mucous 
membrane. 

If  the  pain  is  marked,  the  patient  should  lie  down  for  a  half- 
hour  after  defecation,  holding  a  hot  water  bottle  or  a  hot  wet 
sponge  firmly  against  the  anus. 

By  the  measures  above  mentioned  patients  will  succeed  in 
curing  many  small  fissures  and  in  preventing  many  more.  In 
severer  cases  these  home  remedies  must  be  supplemented  by  treat- 
ment by  the  physician.  Two  plans  have  been  found  reliable, 
namely,  treatment  of  the  wound  by  antiseptics  and  stimulating 
applications  and  stretching  or  division  of  the  sphincter  ani. 

If  applications  are  decided  upon,  the  fissure  should  be  cleansed 
daily.  This  is  best  accomplished  through  a  small  conical  speculum 
with  a  window  in  one  side.  Only  mild  antiseptic  solutions  should 
be  employed,  such  as  bichlorid  of  mercury,  1:  10,000;  boric  acid, 
2  per  cent;  or  peroxid  of  hydrogen,  1  part  to  water  8  parts.  When 
the  fissure  is  clean  and  dry  it  should  be  painted  with  the  stimu- 
lating liquid.  Balsam  of  Peru  (40  per  cent  in  oil);  ichthyol,  20 
per  cent  in  water;  silver  nitrate,  2  to  5  per  cent;  argyrol  or  one 
of  the  other  newer  silver  preparations  in  10  to  20  per  cent  solutions 
are  all  good  remedies. 


ABSCESS  291 

By  far  the  best  treatment  in  many  cases  is  the  stretching  of 
the  sphincter  ani  under  a  general  anesthetic  (p.  282).  This  at 
once  stops  all  spasm  of  the  sphincter,  does  away  with  most  of  the 
pain  during  and  after  defecation,  frees  the  fissure  from  injuri- 
ous contact  with  the  fecal  mass  in  its  passage,  and  without  other 
treatment  in  many  cases  will  effect  a  rapid  cure. 

During  the  stretching  the  fissure  will  probably  be  cracked 
open,  but  if  care  is  taken  not  to  make  the  pull  all  the  while  in 
one  direction,  the  deepening  of  the  fissure  will  not  be  serious.  In 
fact,  this  very  tearing  open  of  the  fissure  itself  has  been  said  to 
be  one  of  the  chief  elements  in  the  rapid  healing  which  follows 
stretching  of  the  sphincter.  This  probably  is  not  so ;  at  any  rate 
there  are  sufficient  other  grounds  on  which  to  explain  the  good 
results  of  this  method  of  treatment. 

There  is  still  another  method  of  treatment  which  has  its  advo- 
cates, and  that  is  division  of  the  external  sphincter  through  the 
fissure.  If  the  fissure  should  happen  to  be  exactly  in  the^a-^terior 
or  posterior  commissure,  the  incision  may  be  made  to  one  or  both 
sides  of  it.  While  this  method  of  treatment  is  unquestionably 
followed  by  a  cure,  it  is  difficult  to  see  why  one  should  enlarge 
the  existing  wound  or  add  two  fresh  wounds,  when  the  relaxation 
of  the  sphincter  can  be  equally  obtained  by  digital  dilatation. 

Abscess. — An  abscess  in  the  vicinity  of  the  anus  or  rectum 
is  generally  called  an  ischiorectal  abscess.  Strictly  speaking,  many 
of  the  abscesses  found  in  this  vicinity  are  not  situated  in  the  ischio- 
rectal space.  The  term  is,  however,  so  well  established  that  it 
will  probably  remain  in  use,  at  any  rate  for  the  deeper  abscesses 
of  the  vicinity. 

It  .is  well  to  recognize  at  least  four  types  of  abscess  in1  this 
vicinity:  (1)  A  cutaneous  furuncle  or  boil;  (2)  an  abscess  beneath 
the  skin  at  the  margin  of  the  anus,  sometimes  called  a  marginal 
abscess;  (3)  an  abscess  within  the  wall  of  the  rectum,  sometimes 
called  an  intramural  or  submucous  abscess;  and  (4)  an  abscess 
outside  of  the  rectum,  which  may  be  designated  a  perirectal  or 
ischiorectal  abscess.  A  still  further  differentiation  is  made  by 
rectal  specialists,  but  this  classification  is  sufficient  for  practical 
purposes. 

The  source  of  infection  in  many  abscesses  can  be  determined. 

Thus  it  is  evident  that  a  furuncle  starts  around  the  root  of  a  hair 
21 


292 


INFLAMMATIONS   OF   THE    ANUS    AND    RECTUM 


or  from  some  abrasion  in  the  skin.  In  marginal  abscess  and  in  a 
submucous  abscess  the  infection  enters  through  a  tissure  or  some 
other  break  of  the  overlying  skin  or  mucous  membrane.  Many 
ischiorectal  abscesses  have  their  origin  in  some  wound  or  ulcer  of 
the  rectum ;  others  are  extensions  of  one  of  the  three  simpler  types 
of  abscesses  mentioned.  In  still  other  cases  no  entering  point  for 
the  infection  can  be  discovered,  and  the  determination  of  the  site 
of  the  abscess  seems  to  follow  a  bruise,  or  unwonted  exercise,  or 
sitting  on  damp  ground,  etc. 

In  the  majority  of  superficial  and  deep  abscesses  of  the  anal 
region  the  pus  contains  bacilli  coli  or  streptococci  or  staphylococci 
or  tubercle  bacilli.  This  is  their  order  of  frequency  according  to 
Gant. 

The  symptoms  are  those  of  abscess  everywhere.  If  the  ab- 
scess is  small  and  superficial  (Fig.   137),  it  will  not  give  much 


Fig.  137. — Small  Superficial  Ischiorectal  Abscess. 

tient  aged  thirty  years. 


Duration  one  week.      Pa- 


pain except  during  defecation  or  when  pressed  upon.  In  other 
cases  the  pain  is  constant  and  intense.  The  deeper  abscesses  are 
usually  situated  either  in  the  right  or  left  ischiorectal  fossa.  Oc- 
casionally they  extend  across  the  posterior  commissure ;  rarely 
across  the  anterior.  Left  to  themselves,  most  of  the  abscesses 
tend  to  "point"  through  the  skin  or  into  the  rectum  (Tig.  138); 
others  burrow  upward  into  the   pelvis,   and   thereby   add  to  the 


ABSCESS  293 

gravity  of  the  situation.  When  the  abscess  hursts,  either  through 
the  skin  or  into  the  rectum,  there  is  a  sudden  discharge  of  pus, 
and  an  equally  sudden  relief  of  symptoms.  Such  a  rupture  usu- 
ally drains  the  abscess  very  imperfectly,  so  that  there  will  be  a 


Fig.  138. — A  Larger  and  Deeper  Ischiorectal  Abscess.      Duration  three   weeks 
Patient  aged  twenty-two  years. 

more  or  less  constant  flow  of  pus,  with  partial  subsidence  of  the 
induration,  and  a  fistula  which  opens  either  into  the  rectum  or 
through  the  skin,  or  in  both  directions,  as  the  case  may  be  (see 
p.  295). 

Treatment. — Treatment  of  an  abscess  of  any  one  of  the  four 
forms  mentioned  should  be  surgical ;  that  is,  the  abscess  should 
be  opened  with  sufficient  freedom  to  permit  the  easy  escape  of 
the  pus,  and  the  incision  should  be  maintained  by  a  drain  or  other- 
wise until  the  abscess  cavity  heals  by  granulation.  A  submucous 
abscess  should  be  incised  longitudinally ;  a  marginal  one,  radially. 
All  other  abscesses  of  this  region  should  be  opened  by  an  incision 
which  is  parallel  to  the  fibers  of  the  sphincter  muscles.  Such  an 
incision  will  correspond  more  or  less  perfectly  to  an  arc  of  a  cir- 
cle drawn  around  the  anus. 

While  a  small  abscess  may  be  opened  without  much  pain  to 
the  patient  by  first  freezing  the  skin  and  then  injecting  cocain,  a 
general  anesthetic  is  advisable  for  three  reasons:  It  saves  the 
patient  from  any  pain ;  it  enables  the  operator  to  explore  more 


294  INFLAMMATIONS    OF  THE   ANUS   AND    RECTUM 

fully  the  deeper  portions  of  the  abscess,  if  such  exisl  ;  and  it  per- 
mits him  to  stretch  the  sphincter.  This  -will  enable  the  operator 
to  determine  whether  the  abscess  communicates  with  or  closely 
approaches  to  the  rectum,  and  it  also  makes  subsequent  defeca- 
tion much  easier,  and  thus  hastens  the  patient's  recovery. 

The  steps  of  the  operation  are  these:  The  patient  is  anes- 
thetized and  placed  either  on  his  hack,  with  his  thighs  well  flexed, 
or  else  upon  the  affected  side.  In  the  latter  case  the  upper  thigh 
should  be  flexed  more  than  the  lower.  A  preliminary  cleansing 
of  the  lower  bowel  and  rectum  by  cathartics  and  enema  is  painful 
and  may  be  omitted.  The  external  parts  are  cleansed,  the  sphinc- 
ter ani  is  dilated  to  a  certain  extent,  the  rectum  is  emptied  by  irri- 
gation, and  the  abscess  cavity  is  incised  either  radially  or  cir- 
cumferentially,  according  to  the  principles  stated  above.  The 
edges  of  the  wound  are  retracted,  and  its  cavity  is  irrigated  with 
hot  saline  solution,  and  explored  with  the  finger  or  a  blunt  pointed 
probe.  Two  points  should  be  determined,  whether  the  pus  has 
burrowed  in  any  direction,  so  that  an  extension  of  the  incision 
is  necessary,  and  secondly,  whether  the  abscess  cavity  communi- 
cates with  the  rectum.  To  determine  the  latter,  one  finger  is 
inserted  in  the  rectum  while  a  probe  is  passed  into  the  different 
portions  of  the  abscess  cavity.  If  the  probe  touches  the  finger,  or 
comes  so  close  to  it  that  only  mucous  membrane  intervenes,  all  of 
the  tissue  between  the  finger  and  the  probe  should  be  divided  by 
a  radial  incision  (see  the  treatment  of  fistula,  p.  297). 

The  cavity  of  the  abscess  should  be  irrigated  with  saline  and 
drained  with  gauze.  It  should  not  be  curetted,  since  the  removal 
of  the  necrotic  lining  of  the  cavity  in  this  manner  wTill  simply 
destroy  the  adjacent  cellular  tissue;  nor  should  septa  be  broken 
down  unless  they  are  so  placed  as  to  interfere  with  drainage. 
They  almost  invariably  represent  blood-vessels  which  have  been 
able  to  maintain  their  vitality  in  spite  of  the  infection  around 
them,  and  they  will  prove  of  assistance  in  the  repair  of  the  wound. 
The  gauze  used  for  drainage  may  be  impregnated  with  iodoform 
or  creolin  or  nosophen  or  covered  with  glutol.  The  cavity  should 
not  be  packed;  only  sufficient  gauze  should  be  used  to  keep  the 
walls  apart. 

If  the  abscess  is  small,  so  that  the  incision  is  short,  it  is  well 
to  remove  from  the  center  of  the  incision  on  one  side  a  triangular 


FISTULA  295 

piece  of  skin.  This  will  facilitate  drainage  and  keep  the  cut 
edges  of  the  skin  from  uniting  before  the  abscess  cavity  has  time 
to  fill  with  granulations. 

Moist  dressings  should  be  employed,  at  least  until  granula- 
tion is  well  established.  The  outer  dressing  should  be  changed  as 
often  as  it  becomes  soiled ;  the  gauze  drainage  in  the  wound  should 
not  be  changed  for  the  first  three  or  four  days.  After  the  first 
week  the  wound  may  be  drained  with  gauze  soaked  with  balsam 
of  Peru,  as  this  does  not  readily  adhere  to  the  wound,  and  dry 
gauze  may  be  used  externally.  In  many  cases  it  is  not  necessary 
for  the  patient  to  remain  in  bed. 

If  the  wound  does  not  heal  completely  within  a  reasonable 
time,  it  is  probably  either  tuberculous  or  communicates  with  the 
rectum.  The  latter  point  may  usually  be  determined  by  the  probe. 
The  former  may  be  inferred  from  the  sluggish  appearance  of  the 
sinus  and  from  the  amount  of  induration  around  it,  and  from  the 
existence  of  tuberculosis  elsewhere  in  the  body.  It  can  be  defi- 
nitely determined  by  the  microscopical  examination  of  a  portion 
of  the  wall  of  the  sinus  removed  under  cocain. 

If  an  ischiorectal  abscess  is  known  to  be  tuberculous  at  the 
time  of  operation  the  treatment  should  be  more  radical  than  that 
outlined  above.  The  abscess  cavity  should  be  incised,  irrigated, 
and  explored  as  there  stated.  The  edges  of  the  wound  should  be 
fully  retracted,  and  all  infiltrated  tissue  dissected  away  with  scal- 
pel or  scissors.  The  life  of  the  patient  may  depend  upon  the 
thoroughness  with  which  this  is  done.  Bleeding  points  should 
then  be  secured,  and  the  wound  drained  and  dressed  as  stated 
above.  An  exception  should  be  made  in  case  the  person  has  in- 
curable tuberculosis  in  the  lungs  or  elsewhere.  Under  such  cir- 
cumstances the  operation  should  be  limited  to  simple  drainage. 

Fistula.  — The  ordinary  fistula  in  ano  is  simply  a  partially 
healed  abscess,  the  complete  healing  of  which  does  not  take  place, 
either  because  drainage  is  imperfect,  or  because  fecal  matter  and 
gas  enter  the  fistula  from  the  rectum,  or  because  the  fistula  is  sur- 
rounded by  an  inflammatory  process  (tuberculosis,  syphilis,  etc.) 
which  the  body  cannot  overcome  (Fig.  139). 

For  practical  purposes  fistulas  about  the  anus  are  of  four  kinds : 
either  blind  external  or  blind  internal  or  complete,  having  both 
an  internal  and  an  external  opening  or  complex.     The  first  three 


296  INFLAMMATIONS   OF  THE  ANUS  AND   KECTUM 

terms  are  sufficiently  descriptive.      Under  the  lasl   we  shall   here 
include  qoI  merely  fistula?  with  more  than  one  branch,  but  those 


Fig.  139. — Fistula  Accompanying  a  Syphilitic  Stricture  of  the  Rectum.     Fe- 
male patient,  aged  forty-four  years. 

with  openings  into  the  vulva,  vagina,  urethra,  or  bladder,  as  well 
as  fistula?  due  to  disease  of  bone. 

Diagnosis. — The  symptoms  of  fistula  are :  The  discharge  more 
or  less  constantly  of  a  small  quantity  of  mucus,  mixed  possibly 
with  blood  or  fecal  matter;  more  or  less  swelling,  induration,  and 
tenderness,  symptoms  which  are  more  marked  when  the  fistula  has 
no  external  opening,  or,  having  one,  drains  imperfectly.  The 
diagnosis  is  usually  made  by  the  patient  before  he  seeks  medical 
advice. 

Examination  will  show  the  external  opening,  if  one  exists. 
It  is  usually  surrounded  by  a  slight  elevation  of  the  skin  or  mu- 
cous membrane,  although  it  is  sometimes  hidden  in  a  fold,  and 
is  sometimes  temporarily  covered  with  intact  epithelium.  Pal- 
pation with  the  finger-tips  will  show  the  presence  of  induration, 
whether  the  fistula  opens  externally  or  not.  The  indurated  tissue 
may  or  may  not  be  tender.  Examination  with  a  probe  should  be 
conducted  with  great  gentleness,  and  if  found  painful  should  be 
at  once  discontinued,  since  the  information  obtained  in  this  man- 
ner has  only  a  slight  value.     In  some  cases  the  fistula  leads  so 


FISTULA  297 

directly  to  the  rectum  that  a  probe  can  be  passed,  and  its  point 
felt  by  the  inserted  finger. 

If  a  fistula  is  submucous  or  subcutaneous  only,  its  external 
opening  is  near  the  anus.  If  the  external  opening  is  farther  away, 
the  fistula  probably  leads  to  the  rectum,  either  through  the  sphinc- 
ters or  above  them. 

Treatment. — A  patient  may  obtain  relief  from  the  pain  of  a 
fistula  by  the  repeated  use  of  a  hot  sitz  bath. 

There  are  three  methods  of  treating  fistula  which  are  likely 
to  effect  a  cure  within  a  short  time,  and  are  therefore  worth  con- 
sideration. They  are  incision,  excision,  and  excision  with  suture. 
The  first  is  the  method  usually  employed. 

The  preparation  of  the  patient  for  operation  is  important. 
In  this  as  in  all  other  rectal  diseases  in  which  a  few  days'  delay 
in  operation  is  not  prejudicial,  the  bowels  should  be  emptied  with 
great  thoroughness.  This  requires  at  least  three  days,  as  no  cathar- 
tics should  be  given  within  twenty-four  hours  of  the  time  set  for 
operation,  and  no  enema  should  be  given  within  twelve  hours  of 
that  time.  If  the  preliminary  treatment  is  thoroughly  carried 
out,  and  a  small  dose  of  morphine  is  given  four  or  six  hours  before 
operation,  the  patient  will  come  to  the  operating-table  with  a  dry 
and  empty  rectum,  and  there  will  be  no  evacuation  during  the 
operation  to  infect  the  operative  wound.  On  the  other  hand,  if 
cathartics  are  given  the  day  before  operation,  and  an  enema  an 
hour  or  so  before  operation,  the  wound  is  almost  certain  to  be 
soiled  with  fluid  feces,  and  the  chance  of  primary  union  is  greatly 
decreased. 

If  the  fistula  is  blind  externally,  the  overlying  tissue  is  split 
up  by  an  incision  more  or  less  parallel  to  the  sphincter  ani,  and 
the  fistulous  tract  is  curetted  or  cauterized.  If  scar  tissue  is 
abundant,  or  if  tuberculosis  is  suspected,  the  tissue  bordering  on 
the  fistula  should  be  dissected  away.  The  wound  may  then  be 
sutured  in  whole  or  in  part. 

If  the  fistula  is  a  blind  internal  one,  similar  principles  should 
govern  the  operator.  The  sphincter  must  be  fully  dilated,  the 
lining  of  the  rectum  carefully  examined  by  means  of  a  specu- 
lum, and  any  openings  explored  in  various  directions,  with  a 
bent  probe.  All  fistula?  should  be  laid  wide  open.  If  a  blind 
internal  fistula  extends  nearly  to  the  skin,   an  external  opening 


298  INFLAMMATIONS  OF  THE   ANUS  AND  RECTUM 

should  be  made,  and  the  case  treated  like  one  of  complete 
fistula. 

The  usual  fistula  in  ano  is  a  complete  fistula,  having  an  open- 
ing- into  the  bowel  and  one  through  the  skin.  The  fistula  itself 
may  lie  beneath  the  mucous  membrane  and  the  skin,  or  it  may 
pass  through  the  sphincter  muscle,  or  between  the  external  and 
internal  sphincter,  or  above  them  both.  When  the  sphincter  has 
been  fully  dilated,  a  probe,  or  liet lei'  still,  a  grooved  director,  is 
passed  through  the  fistula  into  the  bowel,  and  all  the  tissues  lying 
upon  it  are  then  divided.  The  division  of  the  sphincter  should  be 
strictly  a  radial  one.  Many  fistuhc  pursue  an  oblique  course; 
hence,  besides  the  direct  cut  through  the  sphincter  it  may  be  neces- 
sary to  make  an  oblique  incision  in  the  skin,  or  one  parallel  to  the 
fibers  of  the  sphincter.  It  is  possible  in  many  cases  to  excise  the 
the  fistulous  tract,  suture  the  wound,  and  obtain  primary  union. 
The  possibility  of  hidden  suppuration  should  be  borne  in  mind, 
and  if  the  temperature  rises,  or  tenderness  or  swelling  increase 
after  operation,  the  wound  should  be  promptly  reopened  and 
drained. 

Complex  fistula  that  are  of  the  same  nature  as  the  fistula 
already  described  should  be  similarly  treated.  Each  branch  should 
be  thoroughly  laid  open  or  injected  with  a  solution  of  nitrate 
of  silver,  96  grains  to  the  ounce.  Fistula  connecting  with  other 
hollow  organs  in  the  vicinity  present  such  technicalities  in  their 
treatment  that  they  will  not  be  considered  here.  Fistula  due  to 
diseased  bone  will  heal  as  soon  as  the  focus  of  disease  has  been 
obliterated.  Fistula  between  the  anus  and  coccyx  may  be  of  con- 
genital origin  (see  p.  1S1). 

If  the  fistula  is  tuberculous  or  syphilitic,  suitable  constitutional 
treatment  of  the  patient  should  be  instituted.  Tuberculous  fistula 
can  be  healed  even  though  there  are  other  foci  in  the  body,  but 
their  rate  of  healing  is  slow,  and  subsequent  operations  may  be 
necessary. 

Gauze  drainage  is  satisfactory  after  incision  or  excision  of  a 
fistula.  The  bowels  should  be  moved  by  the  third  day,  and  daily 
thereafter  by  mild  laxatives.  After  each  movement  the  wound 
should  be  irrigated  with  hot  saline  solution. 

Gonorrhea. — Gonorrhea  is  occasionally  found  in  the  rec- 
tum, either  as  a  result  of  an  extension  of  the  process  from  the 


CHANCROID  299 

vagina  or  by  direct  infection  from  a  penis  introduced  into  the  rec- 
tum. The  symptoms  are  those  of  a  severe  proctitis,  namely,  burn- 
ing, a  feeling  of  weight,  pain  in  the  rectum  and  back,  greatly 
increased  by  defecation,  and  more  or  less  tenesmus.  There  is  a 
mucous  or  purulent  or  bloody  discharge.  If  the  person  has  been 
subject  to  unnatural  coitus,  the  anus  will  probably  be  relaxed, 
and  the  swollen  mucous  membrane  may  pout  from  the  orifice. 
Often  there  are  erosions  or  fissures  due  to  the  irritating  discharge. 
Frequently  the  patient  will  deny  the  possibility  of  direct  infec- 
tion. The  demonstration  of  the  gonococci  in  a  smear  made  from 
the  discharge  is  the  best  proof  of  the  gonorrheal  character  of  the 
inflammation. 

Treatment. — Pain  can  be  somewhat  relieved  by  a  hot  sitz 
bath  or  by  hot  applications  applied  moist  and  covered  with  oiled 
silk,  and  kept  hot  by  a  hot  bottle  or  brick  (p.  127).  But  if  pain 
is  severe  morphine  must  be  given  in  a  suppository  or  hypoder- 
mically.  The  rectum  should  be  irrigated  twice  daily  with  hot 
saline,  followed  by  a  2  per  cent  boric  acid  solution,  or  one  of 
silver  nitrate,  1 :  3,000,  or  protargol,  1  per  cent,  or  permanganate 
of  potash,  1 :  4,000,  or  even  weaker.  Other  antiseptics  suitable 
for  injection  are  mentioned  on  pages  213  and  263.  If  the  sphinc- 
ter is  tight,  it  should  be  stretched.  This  will  often  relieve  the 
patient  of  a  good  deal  of  the  p^in  both  during  defecation  and  at 
other  times.  Care  must  be  exercised  not  to  make  deep  tears  in 
the  infiltrated  mucous  membrane. 

Chancroid.  — Chancroids  about  the  anus  or  in  the  anal  canal 
may  be  reimplantations  from  chancroids  of  the  genitals,  or  they 
may  be  due  to  direct  infection  from  another  person.  They  are 
far  commoner  in  women  than  in  men.  The  sores  are  usually  mul- 
tiple.    In  character  they  are  similar  to  chancroids  of  the  genitals. 

In  some  cases  there  are  few  symptoms,  and  the  disease  runs  a 
favorable  course.  In  others  the  ulcers  are  phagedenic  in  char- 
acter, or  so  situated  that  defecation  is  very  painful.  The  inguinal 
glands  are  not  infrequently  swollen  and  may  suppurate. 

Treatment. — Most  chancroids  run  a  more  or  less  definite 
course  to  recovery,  but  much  can  be  done  to  prevent  further  infec- 
tion of  the  surrounding  skin.  The  parts  should  be  bathed  twice  or 
three  times  a  day  with  mild  antiseptics,  in  order  to  remove  and 
neutralize  the  discharge.     The  individual  ulcers  may  be  touched 


300 


INFLAMMATIONS   OF   THE   ANUS   AND   RECTUM 


with  stronger  liquids,  such  as  peroxid  of  hydrogen  or  carbolic 
acid  solution,  5  per  cent,  or  with  pure  ichthyol.  Some  writers 
recommend  cauterization  with  the  Paquelin  cautery  or  with 
strong  acids.  Jf  the  spasm  of  the  sphincter  causes  pain,  it  should 
be  stretched,  but  with  great  gentleness,  as  extensive  inflammation 
and  death  has  followed  this  procedure  in  cases  of  chancroids.  In 
all  cases  the  folds  of  the  nates  should  be  kept  from  contact  by  a 
double  layer  of  gauze  or  a  thin  piece  of  cotton  wrung  out  of  an 
antiseptic  solution. 

Syphilis.  — ( Ihancre,  the  primary  lesion  of  syphilis,   is  not 
often  soon  in  the  anal  region.     When  it  does  occur,  it  causes  little 


Fig.    140.- 


-Syphilitic  Condylomata  about  Anus  of  Three  Weeks'  Duration. 
Patient  a  male  aged  sixteen. 


pain  and  heals  promptly,  so  that  Tuttle  suggests  that  the  rarity 
of  its  observation  may  be  the  explanation  of  the  numerous  cases 
of  syphilis  seen  for  the  first  time  in  the  secondary  stage  and  with- 
out any  history  of  a  primary  sore.  Mucous  patches  may  develop 
about  the  anus  and  undergo  hypertrophy,  so  that  their  surface 
presents  something  of  the  appearance  of  cauliflower.     They  have 


ULCER   OF   THE   RECTUM  301 

received  the  name  of  condylomata  lata  (Fig.  140).  The  lesions 
are  apt  to  be  transplanted  from  one  fold  of  skin  to  another. 

Treatment. — The  treatment  is  that  of  syphilis  in  general 
(see  p.  61).  Local  treatment  consists  in  cleanliness  and  protec- 
tion of  the  sore  and  surrounding  skin  by  dusting  the  former  with 
calomel  or  oxid  of  zinc,  or  a  mixture  of  the  two,  and  keeping  a 
fold  of  gauze  between  the  nates. 

Ulcerating  lesions  should  be  cleansed  with  an  antiseptic  solu- 
tion and  dried  and  dusted  with  any  simple  powder,  or  kept  covered 
with  moist  gauze.  The  use  of  blue  ointment  upon  every  syphilitic 
sore  is  a  disgusting  practise  which  happily  is  going  out  of  fashion. 
Tests  show  that  ulcers  do  not  heal  as  rapidly  under  it  as  when 
dressed  with  red  wash  or  some  other  solution,  provided  the  gen- 
eral treatment  of  the  patient  is  the  same. 

Late  Syphilitic  Lesions. — Tertiary  lesions,  both  gumma  and 
diffuse  syphilitic  endarteritis  occur  in  the  rectum.  They  pro- 
duce tedious  ulcers,  as  is  mentioned  below,  and  are  also  of  im- 
portance because  they  may  be  followed  by  stricture  (q.  v.  p.  304). 

Tuberculosis.  — The  anal  region  may  be  the  seat  of  tubercu- 
losis in  the  form  of  ulceration,  either  primary  or  resulting  from 
a  tuberculous  fistula.  In  the  former  case  the  ulceration  is  shallow, 
but  may  spread  over  a  wide  area.  In  the  latter  case  it  may  bur- 
row deeply  into  the  perirectal  spaces.  The  rectum  may  also  be 
the  seat  of  tuberculous  ulceration,  usually  secondary  to  tuberculosis 
of  the  lungs. 

Treatment. — In  these  conditions  the  general  treatment  is  all- 
important.  Unless  the  resisting  power  of  the  individual  can  be 
raised,  local  treatment,  such  as  curettage  or  cauterization,  or  even 
excision  of  the  diseased  tissues,  is  almost  certain  to  be  followed 
by  a  recurrence,  or  rather  extension,  of  the  process.  Hence  it  is 
better  to  confine  the  local  treatment  to  mild  measures,  such  as 
daily  cleansing  with  peroxid  of  hydrogen  solution,  one  part  of 
peroxid  to  eight  of  water,  and  the  application  of  gauze  saturated 
with  balsam  of  Peru,  or  a  solution  of  methyl  blue,  ten  grains 
to  the  ounce.  For  the  treatment  of  tuberculous  fistula  see 
page  297. 

Ulcer  of  the  Rectum. — Ulcer  of  the  rectum  may  be  due  to 
traumatism,  such  as  abrasion  of  the  mucous  membrane  by  hard 
fecal  masses  in  a  person  whose  vitality  is  at  a  low  point ;  or  it  may 


302  INFLAMMATIONS   OF  THE  ANUS   AND   RECTUM 

be  due  to  the  intensity  of  an  inflammatory  process,  either  simple 
or  venereal;  or  it  may  be  due  to  tuberculosis,  or  to  syphilis,  or  to 
a  malignant  growth. 

Diagnosis. — The  symptoms  of  ulcer  of  the  rectum  are  pain, 
diarrhea,  the  discharge  of  mucus,  pus,  or  blood,  excoriation  of  the 
skin  around  the  anus,  tenesmus,  spasm  of  the  sphincter  muscle,  or 
possibly  relaxation  of  the  same  if  the  ulcer  is  of  long  standing. 
These  are  general  symptoms,  some  of  which  will  be  present  in 
every  case  of  ulcer,  no  matter  what  its  cause. 

The  pain  varies  greatly.  It  is  a  prominent  symptom  in  those 
cases  in  which  the  ulcer  is  situated  low  down,  so  that  it  is  grasped 
by  the  sphincter. 

Diarrhea  is  a  prominent  symptom  in  most  cases.  During  the 
night,  when  the  patient  is  in  a  recumbent  position,  there  may  be 
no  stools.  On  rising  he  may  have  two  or  three  in  quick  succession. 
The  diarrhea  is  often  accompanied  with  tenesmus.  The  doctor 
should  never  be  satisfied  to  accept  as  satisfactory  the  patient's  diag- 
nosis of  chronic  diarrhea  without  assignable  cause.  In  many  of 
these  cases  an  ulcer  of  the  rectum  exists,  of  which  the  diarrhea  is 
the  chief  or  only  symptom. 

The  diagnosis  can  be  made  from  the  symptoms,  but  should 
never  be  considered  complete  until  the  mucous  membrane  of  the 
rectum  has  been  inspected  through  the  proctoscope.  For  this  pur- 
pose three  or  four  tubes,  of  varying  sizes  and  lengths,  each  fitted 
with  an  obturator,  are  necessary.  The  patient,  with  the  clothes 
about  the  abdomen  fully  loosened,  is  placed  in  the  knee-chest  posi- 
tion, and  as  large  a  tube  as  the  anus  will  admit  is  passed  in  as 
far  as  it  will  go  readily.  This  is  usually  a  distance  of  four  to  six 
inches.  The  obturator  is  then  withdrawn,  and  light  reflected  from 
a  head  mirror  is  thrown  into  the  rectum.  As  the  tube  is  slowly 
withdrawn  the  mucous  membrane  of  the  rectum  appears,  inch  by 
inch,  at  its  inner  orifice.  In  this  manner  most  of  the  mucous  mem- 
brane of  the  rectum  can  be  inspected,  provided  a  tube  having  a 
caliber  of  at  least  an  inch  can  be  used.  It  is  important  that  the 
rectum  shall  be  empty.  In  many  cases,  when  the  obturator  is  with- 
drawn, air  will  pass  into  the  rectum  and  separate  its  walls  to  a 
certain  extent.  This  facilitates  examination,  and  under  such  cir- 
cumstances a  tube  not  more  than  three  inches  long  may  suffice  for 
the  inspection  of  the  rectum  for  twice  that  distance. 


ULCER   OF   THE   RECTUM  303 

If  the  anus  will  admit  only  a  small  tube,  or  if  the  insertion  of 
any  tube  causes  much  pain,  it  is  better  to  give  an  anesthetic,  mod- 
erately dilate  the  sphincter,  and  insert  a  full  sized  tube.  Special 
proctoscopes  are  made  with  glass  obturators  so  as  to  permit  the 
forcible  distention  of  the  rectum  by  air  pumped  into  it. 

Treatment. — If  spasm  of  the  sphincter  exists,  or  if  there  is 
great  pain  on  defecation,  the  sphincter  should  be  moderately  di- 
lated. The  patient  should  take  as  much  rest  in  bed  as  he  can 
afford.  The  feces  should  be  kept,  if  possible,  in  a  semisolid  con- 
dition, as  they  then  cause  the  least  amount  of  irritation.  The 
rectum  should  be  irrigated  at  least  once  a  day  with  a  warm  normal 
saline  solution.  The  surface  of  the  ulcer  should  be  painted  or 
sprayed  with  stimulating  solutions,  such  as  nitrate  of  silver,  1 
per  cent,  zinc  sulphate,  2  per  cent,  protargol,  5  per  cent,  argonin, 
10  per  cent,  etc.  If  a  stronger  caustic  is  indicated,  a  solution  of 
chlorid  of  zinc,  10  or  20  per  cent,  may  be  used.  A  bit  of  cotton 
is  saturated  with  it  and  held  in  contact  with  the  ulcer  for  some 
minutes.  Another  plan  of  treatment  is  to  apply  the  remedy  chosen 
in  the  form  of  a  suppository  or  in  the  form  of  an  ointment  in- 
jected through  a  special  ointment  syringe. 

In  all  cases  of  ulceration  in  which  the  deeper  tissues  of  the 
rectum  have  been  involved  the  possibility  of  resulting  stricture 
should  be  borne  in  mind.  During  the  later  healing  of  the  ulcer, 
and  for  some  weeks  after  it  has  entirely  healed,  well  lubricated 
flexible  bougies  should  be  passed  at  least  once  a  week  in  order  to 
prevent  the  formation  of  a  stricture.  This  treatment  should  always 
be  carried  out  with  gentleness ;  otherwise  the  induration  and  scar 
formation  will  be  increased  by  it  (p.  306). 

As  the  vitality  of  most  patients  who  suffer  from  ulcer  of  the 
rectum  is  below  normal,  suitable  tonic  treatment  should  always  be 
carried  out.  This  is  especially  true  in  case  of  tuberculous  ulcera- 
tion, and  will  do  far  more  toward  effecting  a  cure  of  the  ulcer  than 
any  number  of  scrapings  or  excisions  of  diseased  tissue. 

In  syphilitic  ulceration  anti syphilitic  treatment  is  the  curative 
treatment,  but  it  should  be  combined  with  the  local  treatment  above 
indicated.  The  frequency  of  stricture  in  these  patients  seems  to 
be  due  in  great  measure  to  the  neglect  of  treatment  during  the 
active  stage  of  the  ulceration. 

The  ulceration  of  malignant  disease  is  an  unimportant  compli- 


304  INFLAMMATIONS   OF  THE   ANUS   AND   RECTUM 

cation,  which  of  itself  does  no!  require  other  than  cleansing  treat- 
ment. 

Stricture  of  the  Rectum. — Stricture  of  the  rectum  may  be 
congenital  or  intlammatory  or  due  to  a  new  growth.  The  first  kind 
is  described  on  page  323,  and  the  last  on  page  317. 

Inflammatory,  or  non-malignant,  stricture  is  due  to  the  con- 
traction of  scar  tissue  following  long  standing  ulceration.  Fre- 
quently stricture  and  ulcer  coexist. 

Diagnosis. — The  symptoms  of  stricture  are  due  in  part  to  the 
obstruction  which  exists,  and  in  part  to  the  accompanying  ulcera- 
tion. The  symptoms  of  ulcer,  as  stated  above,  are  pain,  diarrhea, 
the  discharge  of  mucus,  pus,  or  blood,  excoriation  of  the  skin 
around  the  anus,  tenesmus,  and  spasm,  or  possibly  relaxation  of 
the  sphincter  muscle.  The  symptom  of  the  stricture,  exclusive  of 
ulceration,  is  constipation,  with  its  attendant  disturbances  of  diges- 
tion. Some  patients  go  for  several  days  without  any  movement  of 
the  bowels.  In  other  cases  constipation  alternates  with  diarrhea. 
In  some  cases  the  stool  is  ribbonlike  in  character,  but  this  may  be 
produced  by  a  contracted  sphincter  in  cases  in  which  no  stricture 
exists.  The  symptom  has,  therefore,  little  importance  except  that 
it  indicates  the  necessity  of  a  thorough  examination. 

The  tendency  of  most  strictures  is  to  grow  smaller,  and  for 
that  reason  the  symptoms  of  obstruction  are  likely  to  increase.  At 
any  time  the  obstruction  may  become  absolute,  just  as  it  does  in 
cases  of  malignant  stricture.  When  this  takes  place  neither  gas 
nor  fecal  matter  passes  the  rectum.  The  abdomen  becomes  dis- 
tended, and  in  the  course  of  four  or  five  days  vomiting  will  prob- 
ably set  in.  As  these  patients  are  accustomed  to  infrequent  move- 
ments of  the  bowels,  complete  obstruction  will  sometimes  exist  a 
surprisingly  long  time  before  alarming  symptoms  develop. 

Usually,  before  obstruction  becomes  complete,  the  patient  will 
pass  through  a  number  of  periods  of  partial  obstruction,  attended 
with  griping  pains,  due  to  increased  peristalsis  and  swelling  of  the 
abdomen.  Such  an  attack  is  often  relieved  either  with  or  without 
the  use  of  cathartics  and  enemas,  so  that  in  three  or  four  days  the 
patient's  condition  is  the  usual  one. 

The  stricture  may  be  at  the  anus,  for  instance,  when  it  follows 
a  badly  performed  operation  for  hemorrhoids,  or  it  may  be  within 
easy  reach  of  the  finger,  or  it  may  be  at  the  upper  portion  of  the 


STRICTURE   OF  THE   RECTUM  305 

rectum,  and  so  be  beyond  the  reach  of  the  finger  in  most,  cases.  It 
is  worth  remembering  that  the  rectum  can  be  palpated  digitally 
for  a  greater  distance  when  the  patient  is  in  a  squatting  position 
than  in  any  other  position.  If  the  finger  is  able  to  reach  the  stric- 
ture the  surgeon  should  determine  its  distance  from  the  anus,  its 
caliber,  its  distensibility,  the  amount  of  surrounding  induration, 
and  the  presence  of  an  ulcer.  If  the  finger  can  be  passed  through 
it,  he  should  also  determine  the  extent  of  the  stricture,  both  eircum- 
ferentially  and  longitudinally. 

Further  knowledge  of  the  stricture  may  be  obtained  by  the  use 
of  the  proctoscope,  and  also  by  the  passage  through  it  of  olive 
tipped  or  flexible  bougies. 

In  the  female  vaginal  and  rectal  examination  combined  will 
often  give  added  information  in  regard  to  the  extent  and  form  of 
the  stricture. 

Tkeatment. — The  non-operative  treatment  of  stricture  of  the 
rectum  consists  in  the  regulation  of  the  diet,  which  should  contain 
a  considerable  portion  of  nitrogenous  articles  and  a  good  deal  of 
fat;  in  the  use  of  sufficient  laxatives  to  prevent  the  accumulation 
of  hard  feces  above  the  stricture,  and  in  the  daily  use  of  injections 
to  keep  the  lower  bowel  empty.  If  difficulty  is  experienced  in 
causing  the  injected  fluid  to  pass  the  stricture,  the  enema  may  be 
given  in  the  knee-chest  position.  If  the  stricture  is  due  to  syphilis, 
mercury  and  potassium  iodid  should  be  given;  but  little  benefit 
is  experienced  from  their  use  if  the  stricture  is  an  old  one. 

If  the  above  mentioned  treatment  does  not  relieve  the  patient 
of  pain  and  tenesmus,  hot  applications  to  the  anal  region  should 
be  employed.  The  use  of  anodynes  is  to  be  avoided  as  far  as  pos- 
sible on  account  of  the  tendency  of  these  patients  to  become  drug 
habitues. 

Operative  Treatment. — Several  operations  for  the  treatment  of 
rectal  stricture  have  stood  the  test  of  time.  They  are  gradual  or 
rapid  dilatation,  internal  proctotomy,  external  or  complete  proc- 
totomy, resection,  and,  when  all  other  measures  fail  to  overcome 
the  obstruction,  colostomy.  Only  the  methods  of  dilatation  will 
be  here  described,  since  the  other  procedures  are  outside  the  domain 
of  minor  surgery. 

If  the  stricture  is  within  the  area  of  the  sphincter,  it  should 
be  forcibly  dilated  by  the  fingers  under  a  general  anesthetic.     This 


306  INFLAMMATIONS  OF  THE    ANTS   AND   RECTUM 

■will  save  the  patient  much  time  and  pain.  When  a  sufficienl  cali- 
ber has  been  obtained  in  this  manner  ii  may  be  maintained  by  the 
passage  of  hard  rubber  plugs  every  night  by  the  patient  himself. 
If  the  stricture  is  above  the  level  of  the  sphincters,  its  rapid  dila- 
tation, or  divulsion,  as  it  is  called,  produces  one  or  more  lacera- 
tions of  the  bowel.  These  may  become  infected,  and  they  will 
almost  certainly  add  to  the  amount  of  scar  tissue,  the  contraction 
of  which  will  have  to  be  overcome  in  the  future.  For  these  rea- 
sons gradual  dilatation  is  preferable.  This  may  be  accomplished 
by  the  finger  or  by  flexible  bougies,  if  the  stricture  is  beyond  the 
reach  of  the  finger.  This  treatment,  to  be  successful,  must  be  very 
gentle ;  violence  is  sure  to  excite  the  formation  of  additional  cica- 
tricial tissue.  The  bougie,  well  lubricated,  may  be  passed  under 
the  guidance  of  the  finger  or,  in  difficult  cases,  through  a  speculum. 
This  last  method,  recommended  by  Tuttle,  avoids  the  risk  of  mak- 
ing a  false  passage  with  the  tip  of  the  bougie.  The  first  bougie 
passed  should  be  of  such  caliber  that  it  enters  the  stricture  easily  ; 
the  second  one  should  be  a  little  larger,  and  should  remain  in 
position  until  the  stricture  somewhat  relaxes  its  hold  upon  it.  In 
some  cases  a  third  may  be  passed.  At  the  next  treatment,  two  or 
three  days  later,  the  first  bougie  should  be  slightly  smaller  than 
the  largest  one  employed  at  the  previous  treatment.  An  attempt 
should  not  be  made  to  increase  the  size  of  the  bougies  at  every 
treatment,  lest  too  much  reaction  be  excited.  During  the  treat- 
ment the  patient  should  be  in  a  lateral  position,  with  the  knees 
well  drawn  up,  and  should  not  attempt  to  get  up  for  at  least  fifteen 
or  twenty  minutes  after  the  treatment  is  concluded. 

Internal  proctotomy  is  chiefly  of  service  in  order  to  rid  the 
patient  of  obstruction  caused  by  an  annular  stricture,  or  a  thin 
fold  of  membrane.  There  are  three  such  folds  normally  present, 
sometimes  called  Houston's  folds,  whose  function  it  is  to  keep  back 
the  fecal  masses  from  pressure  on  the  sphincter.  They  may  be- 
come a  real  cause  of  constipation.  They  can  best  be  appreciated 
if  the  patient  is  examined  in  a  squatting  position. 

Complete  or  external  proctotomy,  resection  of  the  rectum,  and 
colostomy  or  the  establishment  of  an  artificial  anus,  are  major 
operations,  which  are  fully  described  in  text-books  on  surgery,  as 
well  as  in  those  on  rectal  diseases. 


CHAPTER    XII 

TUMORS  AND   DEFORMITIES  OF  THE  ANUS  AND 

RECTUM 

BENIGN  TUMORS 

Venereal  "Warts. — Venereal  warts,  or  pointed  condylomata, 
are  small  papillomatous  tumors  which  form  about  the  anus,  as  well 
as  in  the  vicinity  of  the  urethral  orifice.  They  are  not  strictly  of 
venereal  origin,  but  develop  when  the  skin  is  kept  moist  by  any 


Fig.   141. 


-Venereal  Warts  about  the  Anus  of  a  Man  Aged  Twenty-three 
Years.     Duration,  six  months. 


sort  of  an  irritating  discharge.  They  are  covered  by  epithelium, 
which  is  sometimes  so  delicate  that  they  bleed  at  the  slightest 
touch  (Fig.  141).  They  can  be  distinguished  from  the  broad  or 
syphilitic  condylomata  by  the  fact  that  they  always  grow  from 
22  307 


308     TUMORS   AND   DEFORMITIES   OF  THE  ANUS   AND   RECTUM 

slender  pedicles,  and  they  can  be  distinguished  from  malignant 
epithelial  growths  by  the  fact  that  there  is  absolutely  no  indura- 
tion of  the  underlying  true  skin. 

Treatment. — The  warts  should  be  clipped  off  even  with  the 
skin  by  scissors,  and  the  free  hemorrhage  controlled  by  hot  water 
and  pressure.  If  the  warts  are  extensive,  a  general  anesthetic  is 
desirable.  Recurrence  is  unlikely  if  the  parts  are  kept  clean 
and  dry. 

If  the  patient  is  unwilling  to  undergo  this  treatment,  a  slower 
cure  can  be  effected  by  the  use  of  caustics,  of  which  monochloracetic 
acid  is  one  of  the  best. 

Polypus. — This  small  tumor  of  the  anus  or  rectum  has  usu- 
ally a  slender  pedicle  containing  a  small  artery  and  a  soft  body 
made  up  of  flabby  adipose  and  fibrous  or  myxomatous  tissue,  and 
covered  with  either  normal  mucous  membrane  or  with  mucous 
membrane  which  has  undergone  adenomatous  changes.  Such  a 
tumor  may  be  recognized  by  the  palpating  finger  or  it  may  pro- 
trude from  the  anus.  It  often  gives  rise  to  hemorrhage,  but  other- 
wise its  presence  is  not  apt  to  be  noticed  by  the  patient,  unless  it 
projects  externally  or  becomes  caught  in  the  sphincter,  causing  the 
patient  to  feel  that  all  of  the  fecal  matter  has  not  been  evacuated. 
It  may  also  become  inflamed  and  acutely  painful.  If  the  polypus 
is  situated  above  the  reach  of  the  finger,  an  exact  diagnosis  requires 
the  use  of  the  sjDeculum  (p.  281). 

Treatment. — If  the  polypus  is  small  and  easily  accessible  it 
can  be  ligated  and  removed  through  the  speculum,  or  the  defect 
in  the  mucous  membrane  may  be  closed  by  one  or  two  black  silk 
sutures.  If  it  is  of  larger  size  or  has  a  broad  pedicle,  it  is  better 
to  etherize  the  patient,  dilate  the  sphincter,  cleanse  the  rectum, 
remove  the  polyp,  ligate  its  vessels,  and  accurately  close  the  wound 
by  fine  black  silk  interrupted  sutures.  The  aftertreatment  is  the 
same  as  that  which  should  follow  the  removal  of  a  chronic  hemor- 
rhoid (p.  316). 

Hemorrhoids. — A  hemorrhoid  is  a  more  or  less  pedicled 
swelling,  either  within  or  outside  of  the  anus,  which  is  covered 
with  mucous  membrane  or  skin,  and  in  the  center  of  which  are 
one  or  more  dilated  veins.  If  the  hemorrhoid  is  of  long  standing 
it  usually  contains  in  addition  considerable  cicatricial  tissue  of 
inflammatory  origin. 


HEMORRHOIDS 


309 


Hemorrhoids  are  spoken  of  as  external  or  internal,  according 
to  their  situation.  Those  which  are  placed  so  far  outward  as  to 
rest  normally  outside  the  sphincter  ani  are  called  external  hemor- 
rhoids; others  are  spoken  of  as  internal,  although  many  of  them 
do  not  lie  wholly  within  the  sphincter. 

According  to  their  age  and  manner  of  development,  hemor- 
rhoids may  also  be  classed  as  acute  and  chronic. 

Acute  External  Hemorrhoid. — A  hemorrhoid  may  appear  sud- 
denly.    While  the  patient  is  at  stool  or  lifting  a  heavy  weight,  a 


Fig.  142. — Acute  External  Hemorrhoid,  One  Week.  Note  the  dark  point  which 
indicates  a  threatened  rupture  and  discharge  of  the  blood  clot.  Three  years 
previously  a  similar  acute  hemorrhoid  relieved  itself  in  this  way.  Patient  a  man 
aged  forty-four  years. 

vein  about  the  anus  may  rupture  subcutaneously,  causing  the  blood 
to  clot  in  its  lumen  or,  more  often,  outside  of  it.  There  will  then 
be  felt  upon  examination  a  small  rounded  tumor,  containing  in  its 
center  a  solid  elastic  clot  of  blood  (Fig.  142).  If  the  mucous 
membrane  or  skin  which  covers  it  is  edematous  the  blood  clot  can- 
not be  felt  so  perfectly. 


310     TUMORS   AND   DEFORMITIES   OF   THE   ANUS   AND   RECTUM 

Such  a  hemorrhoid  is  sometimes  situated  wholly  outside  of  the 
sphincter  ani,  although  it  is  usually  grasped,  in  part  at  least,  by 
this  muscle.  It  should  not  be  confused  with  a  true  "  strangulated 
hemorrhoid,"  which  is  a  chronic  internal  hemorrhoid,  prolapsed 
and  pinched  by  the  sphincter. 

The  symptoms  of  an  acute  hemorrhoid  are  those  of  discom- 
fort, burning,  and,  if  the  affected  vein  lies  within  the  grasp  of 
the  sphincter  ani,  there  will  also  exist  sharp  pain,  which  grows 
more  acute  in  the  lapse  of  a  few  hours  and  which  is  greatly  in- 
creased upon  defecation,  and  may  even  render  that  act  impossible. 

If  a  hemorrhoid  of  this  character  is  not  treated,  one  of  two 
things  will  follow.  If  the  pressure  upon  the  overlying  mucous 
membrane  or  skin  is  great  enough  to  cause  necrosis,  the  blood  clot 
may  be  discharged,  the  patient  will  be  relieved  of  the  symptoms, 
and  the  tumor  will  shrivel  up  in  part  and  become  one  of  the  exter- 
nal tabs  of  skin  so  often  seen  about  the  anus  and  which  are  some- 
times called  cutaneous  hemorrhoids.  If  necrosis  of  the  overlying 
skin  or  mucous  membrane  does  not  take  place  the  blood  clot  will 
in  time  become  organized,  and  the  tumor  will  decrease  in  size, 
though  remaining  harder  and  larger  than  is  the  case  when  the 
blood  clot  is  discharged. 

Treatment. — The  best  treatment  for  an  acute  hemorrhoid  is 
radial  incision,  or  excision  of  the  most  prominent  part  of  the  over- 
lying skin,  removal  of  the  clotted  blood,  insertion  of  a  bit  of  gauze, 
or  possibly  suture  of  the  wound.  If  the  hemorrhoid  is  situated 
wholly  outside  of  the  sphincter,  this  operation  may  be  performed 
in  a  few  seconds,  either  with  or  without  a  local  anesthetic.  If  the 
lesion  has  caused  great  pain,  it  almost  certainly  extends  upward 
within  the  grasp  of  the  sphincter.  In  this  case  no  operation  should 
be  done  until  after  the  sphincter  ani  has  been  dilated,  and  for 
this  a  general  anesthetic  is  desirable  (see  p.  282). 

If  the  external  acute  hemorrhoid  is  not  seen  until  the  symp- 
toms are  subsiding,  and  the  danger  of  necrosis  of  the  skin  is  past, 
it  may  be  well  to  postpone  operation  and  allow  the  thrombus  to 
organize  and  shrivel  up.  At  any  rate  operation  at  this  stage  will 
not  be  followed  by  the  prompt  collapse  of  the  skin  and  quick 
restoration  to  normal  which  follows  operation  when  the  clot  is 
freshly  formed. 

External  tabs  of  skin,  the  so  called  cutaneous  hemorrhoids,  the 


HEMORRHOIDS  311 

result  of  previous  acute  hemorrhoids,  usually  give  rise  to  no  symp- 
toms.  If  their  presence  is  disfiguring  they  should  he  removed  and 
the  resulting  wounds  sutured  radially  to  the  anus  with  fine  hiack 
silk. 

Chronic  Hemorrhoid. — Another  form  of  hemorrhoid  which  may 
he  spoken  of  as  chronic  to  distinguish  it  from  the  acute  form  above 
described  is  due  to  constipation.  The  dry  hard  fecal  matter  clings 
to  the  mucous  membrane  above  the  sphincter,  and  a  strong  abdom- 
inal pressure  exerted  by  the  patient  to  expel  the  feces  dilates  the 
veins  of  the  rectum  and  those  about  the  anus.  In  the  normal 
individual  in  perfect  health  defecation  can  take  place  without 
straining,  since  the  peristaltic  action  of  the  intestine  is  continued 
down  to  the  anus,  and  is  sufficient  to  expel  the  fecal  mass.  When 
the  feces  is  allowed  to  remain  for  hours  each  day  in  the  rectum, 
the  latter  becomes  tolerant  of  its  presence,  so  that  it  is  difficult 
to  excite  it  to  peristaltic  action  during  the  act  of  defecation. 

In  time  the  dilatation  of  the  veins  become  permanent,  and 
although  the  change  may  not  be  noticeable  when  the  parts  are  at 
rest,  it  is  evident  when  the  patient  strains.  This  gives  a  puffy 
appearance  to  the  skin  around  the  anus.  These  dilated  masses 
of  veins,  with  their  covering  of  skin,  are  called  chronic  external 
hemorrhoids. 

From  this  repeated  straining  at  stool,  and  from  the  long  reten- 
tion of  feces  in  the  rectum,  the  caliber  of  the  lower  portion  of 
the  rectum  becomes  excessive,  and.  when  it  is  empty  the  superfluous 
mucous  membrane  is  naturally  thrown  into  folds.  Such  a  fold 
covering  a  mass  of  dilated  veins  is  known  as  an  internal  hemor- 
rhoid. At  each  defecation  it  is  dragged  downward,  and  in  time 
comes  to  assume  the  shape  of  a  pedicled  tumor.  One  or  more  of 
these  internal  hemorrhoids  may  protrude  from  the  anus  after 
defecation  until  replaced  by  the  fingers   (Fig.  143). 

If  the  hemorrhoids  are  large  and  the  sphincter  ani  by  reason 
of  the  irritation  of  the  parts  has  tightened  its  grasp,  the  reduction 
of  the  hemorrhoids  may  be  attended  with  difficulty.  In  this  man- 
ner a  true  strangulation  of  a  hemorrhoid  may  take  place,  and 
result  in  gangrene  of  a  portion  of  its  mucous  membrane. 

In  the  usual  case  of  chronic  hemorrhoids,  there  may  be  one  or 
two  of  the  folds  above  described  or  a  complete  circle  of  them,  or 
the  whole  lower,  segment  of  the  rectum  may  become  so  loosened 


312     TUMORS    A.\D   DEFORMITIES   OF   THE   ANUS   AND   RECTUM 

and  dilated  that  it  turns  outward  during  the  act  of  defecation, 
thus  simulating  the  normal  behavior  of  the  rectum  of  the  horse 
during   defecation. 

Symptoms. — The  symptoms  arising  from  chronic  hemorrhoids 
vary  greatly  according  to  the  situation  of  the  dilated  veins  and 


Fig.  143. — Internal  Hemorrhoids  of  Sixteen  Years'  Duration.     Patient  aged 

fifty-two  years. 

whether  or  not  inflammation  is  present.  Chronic  external  hemor- 
rhoids existing  alone  often  give  rise  to  no  symptoms  Avhatever,  or 
possibly  to  a  slight  burning  sensation  after  defecation,  possibly  to 
pruritus.  Internal  hemorrhoids,  on  the  other  hand,  are  far  more 
painful,  and  when  well  developed  they  bleed  easily  and  interfere 
with  defecation.  These  patients  are  almost  invariably  constipated, 
and  while  constipation  is  one  of  the  chief  factors  in  the  causation 
of  hemorrhoids,  it  often  happens  that  laxatives  by  temporarily 
increasing  the  size  of  the  tumors,  and  the  freedom  with  which 
they  protrude,  add  to  the  discomfort  of  the  patient.  The  pain 
may  be  constant  or  it  may  be  caused  by  defecation,  and  last  for 
half  an  hour  or  so  after  the  rectum  has  been  emptied.  The  hem- 
orrhage is  of  variable  quantity.  It  is  usually  due  to  abrasions 
of  the  mucous  membrane,  caused  by  the  passage  of  hard  fecal  mat- 
ter through  the  sphincter,  or  to  abrasions  caused  by  the  patient, 
if  the  mucous  membrane  protrudes  from  the  anus  and  he  uses  a 


HEMORRHOIDS  313 

rough,  dry  paper  to  cleanse  himself  or  to  relieve  the  itching.  Hem- 
orrhage may  also  be  due  to  congestion  or  ulceration  within  the 
rectum;  and  if  so,  it  usually  occurs  in  greater  quantity  than 
when  it  is  due  to  the  mechanical  abrasions  spoken  of.  The  itch- 
ing may  be  intolerable.  This  may  be  the  chief  or  only  symptom 
of  hemorrhoids,  and  hence  the  term  itching  piles.  It  is  appar- 
ently due  to  the  disordered  circulation  about  the  anus,  and  if  so, 
disappears  with  the  relief  of  the  hemorrhoids.  But  pruritus  ani 
may  exist  without  hemorrhoids  (see  p.  287),  and  may  therefore 
coexist  independently. 

Treatment.- — The  non-operative  treatment  of  hemorrhoids  is 
of'  importance  because  it  may  relieve  all  symptoms  in  the  milder 
cases,  and  because  many  patients  absolutely  refuse  operation,  even 
when  it  is  clearly  indicated.  If  the  regulation  of  the  diet  and 
mode  of  life  is  not  sufficient  to  overcome  constipation,  mild  laxa- 
tives should  be  given.  Straining  at  stool  is  to  be  avoided,  even 
though  a  small  injection  of  cold  water  has  to  be  used  each  time. 
The  patient  should  make  it  a  practise  after  the  rectum  is  empty  to 
contract  the  sphincter  four  or  five  times  with  considerable  force. 
Bathing  with  cold  water  will  also  improve  the  tone  of  the  tissues, 
and,  when  possible,  these  measures  should  be  followed  by  a  few 
minutes'  rest  in  a  recumbent  position  or  with  the  hips  elevated. 

Local  treatment  will  naturally  be  directed  to  the  relief  of  the 
most  annoying  symptoms:  thus,  if  the  patient  is  annoyed  with 
itching,  the  parts  should  be  painted  with  a  five  per  cent  solution 
of  carbolic  acid  or  a  salve  containing  tannic  acid  and  ichthyol, 
each  one  part,  belladonna  ointment  and  the  cerate  of  lead  subace- 
tate,  each  five  parts.  Tor  the  bleeding  and  pain  of  internal  hem- 
orrhoids, a  multitude  of  salves  and  suppositories  has  been  recom- 
mended. Perhaps  as  good  as  any  is  a  suppository  containing 
two  grains  of  iodoform  and  five  of  tannic  acid,  with  the  addition 
of  a  small  quantity  of  morphine,  if  the  pain  is  great. 

Hemorrhage  is  for  the  most  part  not  serious,  unless  on  account 
of  its  frequent  recurrence.  Any  particular  bleeding  either  ceases 
spontaneously  or  will  usually  do  so  as  soon  as  the  patient  assumes 
a  horizontal  position  or  applies  cold  and  pressure  to  the  anus. 

A  prolapsed  hemorrhoid  can  usually  be  replaced  by  a  few 
moments'  steady  pressure.  This  is  more  effectual  if  the  mucous 
membrane  of  the  opposite  side  of  the  bowel  is  drawn  outwai*d 


;;i  1     TUMORS   AND   DEFORMITIES  OF  THE  ANUS   AND  RECTUM 

before  the  pressure  is  made,  lis  return  will  then  assist  in  drag- 
ging the  prolapsed  hemorrhoid  back  into  place.  The  patient  usu- 
ally learns  to  make  this  manipulation  himself.  If  he  fails  on  ac- 
count of  pain  or  swelling,  the  prolapsed  hemorrhoid  will  rapidly 
increase  in  size,  so  that  in  an  hour  or  two  its  reduction  will  be 
more  difficult.  If  left  out  for  a  longer  period  it  may  become  gan- 
grenous in  part. 

The  application  of  cold  by  an  ice-bag  or  cracked  ice  will  re- 
duce the  swelling  and  favor  reduction.  Constant  elastic  pressure 
obtained  by  a  big  pad  of  nonahsorbont  cotton  and  a  firm  T-band- 
age  may  in  an  hour  or  two  reduce  the  prolapsed  hemorrhoid.  The 
cotton  should  be  separated  from  the  hemorrhoid  by  a  layer  of 
gauze  spread  with  any  simple  ointment. 

If  these  measures  fail,  or  if  immediate  reduction  is  desirable 
on  account  of  intense  pain,  the  patient  should  be  given  a  general 
anesthetic  and  the  sphincter  ani  dilated.  Return  of  the  prolapsed 
hemorrhoids  is  then  accomplished  with  the  greatest  ease.  A  rub- 
ber tube  left  in  the  rectum  will  allow  the  escape  of  gas. 

While  the  palliative  treatment  above  indicated  will  relieve  the 
symptoms  in  mild  cases  of  hemorrhoids,  they  are  ill  adapted  to 
severe  cases.  In  these  the  gross  lesions  are  so  marked  that  one 
does  his  patient  an  injustice  who  does  not  advise  him  to  submit 
himself  to  operation. 

Operative  Treatment. — The  curative  treatment  of  chronic 
hemorrhoids  consists  in  the  dilatation  of  the  sphincter  ani  and  the 
removal  of  the  superfluous  skin  or  mucous  membrane  and  the 
underlying  dilated  veins.  This  may  mean  the  removal  of  a  single 
fold  or  several  folds,  or  the  removal  of  a  complete  circle  of  the 
bowel  in  cases  in  which  there  is  so  much  prolapse.  The  wounds 
caused  in  the  mucous  membrane  and  skin  should  be  carefully 
stitched  with  fine  black  silk  after  the  veins  and  arteries  have 
been  ligated  and  excised.  In  other  words,  the  same  surgical  prin- 
ciples should  be  applied  here  as  are  followed  in  the  removal  of 
superfluous  tissue  in  other  portions  of  the  body.  ~No  one  would 
think  of  clamping  an  angioma  of  the  cheek,  ligating  or  cauteri- 
zing its  stump,  and  leaving  the  wound  to  heal  by  granulation.  The 
rectum  should  be  treated  with  no  loss  respect.  The  rapidity  with 
which  the  parts  will  heal,  the  absence  of  pain,  and  the  lack  of 
any  visible  scar  will  be  a  surprise  to  those  who  have  only  seen 


HEMORRHOIDS  315 

hemorrhoids  treated  by  the  older  methods.  As  far  as  possible  the 
suture  lines  should  be  made  longitudinal  to  avoid  subsequent  con- 
traction of  the  anus. 

Technic  of  Operation. — Whenever  possible,  three  days  should 
be  allowed  to  prepare  the  patient  for  operation,  as  this  preparation 
is  most  important.  The  bowels  should  be  thoroughly  moved  three 
days  before  operation  and  two  days  before  operation.  On  the  day 
immediately  preceding  operation  one  or  two  rectal  enemas  should 
be  given.  After  this  the  rectum  should  not  be  disturbed.  It  will 
then  be  found  clean  and  free  from  fluid  at  operation.  For  the 
last  day  the  diet  should  be  fluid  and  of  a  character  to  leave  little 
residue,  and  a  small  dose  of  morphine  may  be  given  a  few  hours 
before  operation. 

The  patient  is  anesthetized  and  placed  in  the  lithotomy  posi- 
tion. The  sphincter  is  slowly  but  completely  dilated  (p.  282). 
A  bivalve  speculum  is  inserted  and  opened  in  different  directions, 
so  that  the  operator  may  determine  the  amount  of  hemorrhoidal 
tissue  which  it  is  desirable  to  resect.  The  speculum  is  removed 
and  an  individual  hemorrhoid  is  clamped  longitudinally.  The 
mucous  membrane  and  the  skin,  if  the  hemorrhoid  extends  so  far 
downward,  is  divided  on  either  side  of  the  clamp,  and  dissected 
and  pushed  back  from  the  central  mass  of  vessels.  The  pedicle 
of  the  hemorrhoid,  which  is  composed  chiefly  of  vessels,  is  trans- 
fixed and  ligated  in  two  sections  with  fine  catgut.  The  upper 
portion  of  the  wound  in  the  mucous  membrane  is  then  closed  by  a 
continuous  suture  of  fine  chromic  catgut.  Before  this  is  drawn 
taut  the  portion'  of  hemorrhoid  included  in  the  clamp  is  cut  away. 
Care  should  be  taken  to  cut  far  enough  away  from  the  ligatures 
on  the  pedicle  so  that  they  will  not  slip  off.  The  chromic  catgut 
suture  is  then  continued  until  the  wound  is  closed ;  or  if  preferred 
the  upper  half  of  the  wound  only  is  closed  in  this  way,  and  the 
lower  half  is  stitched  with  fine  black  silk.  •  This  causes  less  irri- 
tation, and  almost  never  suppurates;  but  it  is  difficult  to  remove, 
without  anesthesia,  stitches  more  than  an  inch  above  the  normal 
lower  level  of  the  anus. 

Other  hemorrhoids  are  treated  in  this  manner  until  the  normal 
contour  of  the  bowel  has  been  restored.  One  should  be  careful 
not  to  remove  too  much  of  the  mucous  membrane  aud  skin,  espe- 
cially in  the  anal  canal,  lest  a  stricture  result.     It  is  rarely  de- 


310     TUMORS   AND   DEFORMITIES   OF  THE  ANUS   AND   RECTUM 

sirable  to  remove  more  than  four  clampfuls  of  tissue.  The  clam]) 
should  never  contain  mure  than  one-eighth  of  the  total  circumfer- 
ence of  the  bowel. 

Internal  hemorrhoids  are  often  continuous  with  external  ones, 
and  if  such  is  the  case,  the  radial  excisions  of  mucous  membrane 
should  be  continued  outward  far  enough  to  remove  the  surplus 
skin,  and  permit  the  ligation  and  excision  of  the  dilated  under- 
lying veins.  The  remaining  skin  will  "  fit  "  more  smoothly  if  the 
line  of  suture,  strictly  longitudinal  within  the  rectum,  becomes  a 
spiral  one  when  it  passes  outside  of  the  anus. 

Postoperative  Treatment. — After  the  operation  the  patient 
should  be  kept  on  a  fluid  diet  for  two  days.  The  white  of  an  egg, 
stirred  raw  into  a  half-glass  of  water,  probably  leaves  as  little 
residue  in  the  intestine  as  any  form  of  nourishment.  A  little 
fruit  juice  may  be  added  for  taste.  This  may  be  given  every  two 
or  three  hours.  The  bowels  should  be  moved  by  a  laxative  on  the 
third  or  fourth  day,  and  after  that  the  patient  may  get  up,  though 
if  he  can  afford  a  longer  rest,  so  much  the  better. 

All  things  considered,  this  plan  of  treatment  seems  the  best 
that  has  been  devised.  It  is  the  cleanest,  gives  the  smallest  wound 
for  the  work  done,  and  is  followed  in  most  cases  by  primary  union. 
The  various  forms  of  office  treatment  by  means  of  electrolysis, 
injections  of  carbolic  acid,  etc.,  prolong  the  patient's  discomfort 
for  several  weeks,  even  if  they  do  not  add  to  it,  and  often  fail  to 
effect  a  cure. 

MALIGNANT   TUMORS 

Carcinoma. — Cancer  of  the  anus  and  rectum  is  a  common 
disease,  especially  in  men  over  thirty  years  of  age.  It  may  origi- 
nate in  the  skin  around  or  within  the  anus,  in  which  case  it  is  a 
squamous  epithelioma ;  or  it  may  originate  in  the  mucous  mem- 
brane of  the  rectum,  in  which  case  it  may  be  of  any  one  of  the 
types  of  cancer  which  are  found  growing  from  mucous  membrane. 
In  more  than  one-half  the  cases  the  tumor  involves  the  supraperi- 
toneal portion  of  the  rectum ;  while  in  about  one-fourth  of  the  cases 
it  involves  the  infraperitoneal  portion  of  the  rectum  or  the  anus. 
In  these  latter  situations  it  is  easily  accessible  to  the  finger,  and 
there  is,  therefore,  the  less  excuse  for  failure  to  make  an  early 
diagnosis.     Tet  so  strong  is  the  dislike  of  many  physicians  for  a 


SARCOMA  317 

rectal  examination  that  patients  are  frequently  seen  with  well  de- 
veloped carcinoma  of  the  rectum  who  have  been  treated  for  con- 
stipation, hemorrhoids,  etc.,  for  months  without  a  physical  exami- 
nation being  made.  This  is  a  sufficient  excuse,  if  any  is  needed, 
for  introducing  this  serious  subject  into  a  book  on  minor  surgery. 

Diagnosis. — The  diagnosis  in  anal  carcinoma  is  easily  made, 
since  at  least  a  part  of  the  growth  is  visible.  There  will  be  in- 
duration of  the  skin  and  a  hard  tumor,  slightly  elevated,  and  pre- 
senting in  its  older  portions  cracks  or  ulcers  partially  covered  by 
scabs.  Microscopic  examination  of  a  section  of  the  tumor  will 
remove  any  doubt  which  may  exist  as  to  its  nature. 

The  early  symptoms  of  carcinoma  situated  above  the  anal  canal 
are  irregularity  in  the  stools,  constipation  or  diarrhea,  and  a  dis- 
charge of  mucus  or  pus  or  blood,  the  discharge  usually  having  an 
extremely  foul  odor.  The  discharge  frequently  causes  erosions  of 
the  skin  about  the  anus.  The  amount  of  pain  varies  in  different 
cases.  The  fact  that  it  is  often  a  late  symptom  is  no  doubt  one 
reason  why  these  tumors  sometimes  attain  so  great  a  size  before 
surgical  aid  is  called  for. 

If  the  carcinoma  is  within  reach  of  the  finger,  it  can  be  rec- 
ognized as  a  hard,  nodular  growth,  more  or  less  elevated  above 
the  level  of  the  mucous  membrane  of  the  rectum.  It  is  inelastic, 
so  that  if  it  extends  through  more  than  one-half  of  the  circumfer- 
ence of  the  rectum,  the  caliber  of  the  latter  is  distinctly  reduced. 
If  it  extends  all  the  way  around  the  rectum,  there  is  usually  a 
well  marked  stricture. 

The  fact  that  no  tumor  can  be  reached  with  the  finger  is  no 
proof  that  the  rectum  is  free  from  cancer,  since  it  may  be  situ- 
ated too  high  up  to  be  accessible  in  this  manner.  In  every  such 
case,  therefore,  an  examination  with  the  speculum  should  be  made. 

Sarcoma.  — Sarcoma  of  the  rectum  starts  outside  of  the  mu- 
cous membrane,  so  that  at  first  the  mucous  membrane  is  movable 
over  it.  For  the  same  reason  ulceration  is  not  an  early  symptom, 
nor  is  gangrene  of  the  surface,  with  its  characteristic  odor,  so 
prominent  a  symptom.  Sarcoma  may  obstruct  the  rectum  by  its 
bulk,  but  does  not  tend  to  form  a  cicatricial  stricture. 

Treatment. — This  is  not  the  place  to  consider  the  treatment 
of  cancer  of  the  rectum,  but  the  matter  is  such  an  important  one 
that  it  cannot  be  insisted  upon  too  strongly  that  every  physician 


318     TUMORS   AND   DEFORMITIES   OF   THE  ANUS   AND   RECTUM 

who  is  consulted  by  a  patient  for  the.  relief  of  rectal  symptoms 
should  make  a  careful  digital  examination,  and  if  the  diagnosis 
is  not  perfectly  clear,  an  examination  with  the  speculum  should 
also  be  made.  Were  this  the  rule  fewer  malignant  troubles  would 
go  so  long  unsuspected. 

ACQUIRED    DEFORMITIES 

Prolapse.  — Acute  prolapse  of  the  rectum  is  often  seen  in 
young  infants.  At  an  early  age  the  rectum  is  a  delicate  structure, 
more  like  the  small  intestine  in  the  adult  than  like  the  adult  rec- 
tum. It  is  loosely  attached  in  the  pelvis,  and  is  therefore  .easily 
everted  by  excessive  straining  at  stool,  either  the  result  of  con- 
stipation or  of  diarrhea.  Such  a  prolapse  usually  measures  from 
one  to  three  inches  in  length  and  can  hardly  be  mistaken  for  any- 
thing else.  It  is  a  soft  tumor  covered  with  mucous  membrane, 
either  in  a  normal  state  or  congested  or  edematous  or  gangrenous, 
according  to  the  amount  of  constriction  of  the  anus  and  the  dura- 
tion of  the  prolapse. 

It  sometimes  happens  that  an  invagination  of  the  gut  above  the 
rectum  may  appear  at  the  anus.  Even  so  high  an  invagination 
as  that  of  the  small  intestine  through  the  iliocecal  valve  has  been 
known  to  protrude  from  the  anus.  Under  these  circumstances  the 
protruding  gut  is  apt  to  be  in  a  serious  condition.  If  the  rectum 
alone  has  prolapsed  its  vitality  is  not  seriously  affected  in  most 
cases. 

Treatment. — The  treatment  indicated  in  acute  prolapse  is 
the  immediate  replacement  of  the  protruding  bowel.  The  patient 
should  be  placed  in  some  position  which  will  bring  the  hips  well 
above  the  epigastrium.  A  small  child  may  be  inverted,  if  this 
can  be  done  without  exciting  crying.  Delicate  manipulation  with 
the  fingers  will  usually  succeed.  As  in  reducing  a  hernia  this 
may  be  carried  out  in  two  ways :  The  protruding  mass  may  be 
grasped  with  the  hand  and  compressed,  much  as  one  compresses 
the  bulb  of  a  hand  syringe.  This  pressure  may  force  the  central 
part  of  the  prolapse  back  into  the  rectum,  and  if  so  the  rest  will 
easily  follow.  The  other  method  is  to  push  upward  the  lowest 
part  of  the  prolapse  with  the  finger.  The  trouble  with  this  method 
is  the  difficulty  in  preventing  the  prolapse  from  recurring  when 
the  finger  is  withdrawn.     A  good  plan  is  to  wrap  the  finger  with 


CHRONIC  PROLAPSE  319 

dry  gauze  or  tissue  paper,  which  sticks  to  the  mucous  membrane, 
and  then  by  rotation  of  the  finger  to  unwind  this  from  the  finger, 
leaving  it  in  the  rectum  until  the  prolapse  has  been  entirely  re- 
duced. 

It  is  necessary  to  prevent  a  recurrence  of  the  prolapse  for  some 
weeks.  Sufficient  laxatives  or  enemata  should  be  given  to  pre- 
vent straining  at  stool.  Defecation  should  take  place  in  a  hori- 
zontal position,  either  on  the  back  or  side.  The  buttocks  should  be 
tightly  strapped  together  with  adhesive  plaster.  If  this  becomes 
soiled,  the  central  part  should  be  cut  away  and  new  strips  placed 
over  the  old,  as  the  daily  peeling  off  of  the  old  and  application 
of  new  strips  will  make  the  skin  sore  in  a  short  time. 
.  :  In  infants  a  cure  can  almost  invariably  be  effected  by  these 
means. 

If  the  prolapse  is  due  to  an  invagination  above  the  rectum, 
merely  crowding  the  gut  back  within  the  anus  will  not  of  course 
relieve  the  trouble.  Something  may  be  accomplished,  however, 
digitally  or  by  the  injection  of  warm  oil  combined  with  inversion 
of  the  patient.  If  these  simple  means  are  not  sufficient  to  effect 
a  cure  within  a  few  hours  after  the  first  symptoms,  laparotomy 
should  be  performed. 

Chronic  Prolapse. — In  the  lesser  degrees  of  this  condition 
there  is  a  protrusion  after  defecation  of  the  mucous  membrane. 
In  the  severer  degrees  not  only  the  mucous  membrane,  but  all  the 
coats  of  the  rectum  are  turned  out,  and  when  replaced,  they  again 
prolapse  as  soon  as  the  patient  assumes  an  upright  position  and 
takes  a  few  steps. 

The  causes  of  chronic  prolapse  are  the  same  as  the  causes  of 
chronic  hemorrhoids,  namely,  dilatation  and  atony  of  the  rectum 
and  straining  to  expel  a  constipated  movement.  Prolapse  is  also 
favored  by  the  overstretching  or  laceration  of  the  perineum  at 
childbirth,  by  unwise  operations  upon  the  rectum  leading  to  paral- 
ysis of  the  sphincter  ani,  as  well  as  by  the  relaxation  of  the  tissues 
which  comes  with  old  age.  It  is  therefore  especially  frequent  in 
old  and  feeble  persons,  though  by  no  means  confined  to  them. 

Diagnosis. — The  symptoms  are  slight,  the  annoyance  of  the 
protruding  mass  covered  with  mucous  membrane  being  often  the 
only  one.  If  this  ulcerates,  there  will  of  course  be  a  purulent  and 
slightly  bloody  discharge.     The  diagnosis  is  always  easy,  though 


320     TUMORS    AND    DEFORMITIES   OF   THF    ANUS    AND    RECTUM 

it  may  not  be  so  easy  to  say  just  what  is  the  degree  of  prolapse, 
nor  whether  it  is  accompanied  by  a  hernial  protrusion  or  not. 

Treatment. — The  treatment  outlined  for  acute  prolapse  can- 
not be  expected  to  cure  chronic  prolapse;  the  conditions  are  too 
different;  and  yet  something  may  be  accomplished  by  attention 
to  the  bowels,  the  use  of  cold  water  both  within  and  outside  of  the 
rectum  to  tone  up  the  muscles,  and  by  rectal  and  abdominal  mas- 
sage. Astringents  may  also  be  used  within  the  rectum  (see  p. 
:)13)  or  applied  to  the  protruding  bowel. 

The  bowel  may  be  stiffened  by  the  injection  of  irritating  fluids 
into  its  tissues,  or  by  the  cauterization  of  its  surface.  It  is  evi- 
dent that  anything  which  will  reduce  the  flexibility  of  the  rectum 
will  make  it  less  easy  for  a  prolapse  to  occur.  It  is  claimed  by 
the  advocates  of  this  plan  of  treatment  that  the  caliber  of  the 
rectum  is  also  reduced  thereby.  A  fluid  commonly  employed  for 
intramural  injection  is  composed  of  the  following  substances: 

I)    Salicylic  acid    1  part ; 

Sodium  biborate 2  parts ; 

Carbolic  acid   4       " 

Glycerin    16       " 

A  few  minims  are  injected  in  two  or  three  places  around  the 
neck  of  the  prolapse,  and  after  a  few  minutes  the  reduction  is 
made.  For  two  weeks  thereafter  the  patient  should  keep  the 
buttocks  strapped  together,  and  should  defecate  in  a  horizontal 
position. 

Cauterization  of  the  protruded  rectum  may  be  performed 
with  a  strong  acid  or  w7ith  the  Paquelin  cautery.  It  is  recom- 
mended that  this  cauterization  be  made  in  longitudinal  lines, 
from  four  to  six  according  to  the  size  of  the  bowel.  Another 
plan  is  to  reduce  the  prolapse  and  insert  a  speculum  having  six 
narrow  slits  in  it,  so  placed  that  they  are  wholly  above  the  anal 
canal  when  the  speculum  is  inserted.  The  mucous  membrane 
projects  through  these  slits  into  the  lumen  of  the  speculum,  and 
can  be  readily  and  accurately  cauterized. 

If  these  simpler  measures  fail  there  are  a  number  of  opera- 
tions to  choose  from,  such  as  excision  of  longitudinal  or  circular 
strips  of  mucous  membrane ;  enfolding  of  a  longitudinal  fold  of 
the  whole  rectum  through  a  posterior  incision;  suspension  of  the 


INCONTINENCE  OF  THE  SPHINCTER  ANI  321 

rectum  through  a  posterior  or  an  abdominal  incision,  etc.  The 
details  of  these  and  other  operations  are  found  in  special  and 
general  text-books. 

Rectal  hernia,  with  prolapse  of  a  part  of  the  rectum,  is 
found  in  women  whose  sphincter  ani  has  been  damaged  in  child- 
birth. Such  a  prolapse  is  of  the  nature  of  a  hernia,  the  outer 
portion  of  which  is  covered  with  the  everted  mucous  membrane 
and  within  which  there  may  be  a  portion  of  the  vagina  or  the 
uterus  or  the  intestine  or  other  contents  of  the  peritoneal  cavity. 
Such  a  hernia  is  always  easily  reducible.  Its  cure  is  to  be  sought 
by  restoration  of  the  sphincter  ani. 

Incontinence  of  the  Sphincter  Ani. — Inability  of  the  pa- 
tient to  retain  his  feces  may  be  due  to  a  great  number  of  causes, 
such  as  injury  to  the  spinal  cord,  other  forms  of  paralysis,  rup- 
ture or  division  of  the  sphincter,  rigidity  of  the  anal  canal,  as 
seen  in  cases  of  malignant  disease,  etc. 

A  patient  may  be  able  to  retain  solid  fecal  matter,  but  un- 
able to  retain  fluid  feces.  This  is  frequently  the  case  after  resec- 
tion of  the  rectum  for  malignant  disease. 

Diagnosis. — The  diagnosis  of  incontinence  is  easily  made 
from  the  statement  of  the  patient  or  those  who  care  for  him.  But 
the  mere  knowledge  of  this  one  symptom  is  not  a  satisfactory  diag- 
nosis. The  physician  must  ascertain  whether  incontinence  exists 
at  all  times,  and  if  not,  under  what  circumstances  it  occurs.  He 
must  also  continue  his  examination  until  he  has  learned  the  exact 
cause  of  the  lack  of  control.  If  proctitis  exists,  or  an  ulcer  or 
a  stricture  or  malignant  disease,  appropriate  treatment  is  to  be 
instituted.  If  the  loss  of  sphincteric  control  has  followed  a  trau- 
matism or  an  operation  for  hemorrhoids,  fistula,  or  abscess,  the 
physical  examination  should  reveal  the  ability  of  the  patient  to 
contract  the  sphincter  ani  muscle  or  its  segments  in  case  it  has 
been  divided  in  more  than  one  place.  These  are  the  cases  in  which 
a  slight  operation  may  cure  or  benefit  a  patient  otherwise  very 
miserable. 

Treatment. — If  examination  shows  that  there  is  no  paralysis 
of  the  sphincter,  but  that  loss  of  control  is  due  to  separation  of 
the  cut  ends  of  the  muscle,  an  operation  should  be  performed  to 
reestablish  its  continuity.  This  should  not  be  performed  as  long 
as  any  ulcer  or  sinus  exists. 


322     TUMORS   AND   DEFORMITIES   OF  THE   ANUS   AND   RECTUM 

The  patient  should  be  prepared  as  for  other  rectal  operations 
(p.  315).  A  general  anesthetic  is  desirable.  A  circular  incision 
should  be  made  at  a  distance  of  a  half  inch  or  more  from  the  mar- 
gin of  the  anus,  and  long  enough  to  expose  the  cut  ends  of  the 
sphincter  ani.  Both  of  these  are  freed  by  careful  dissection,  the 
intervening  scar  tissue  is  cut  away,  and  the  clean  ends  of  the  mus- 
cle are  closely  approximated  by  three  or  four  sutures  of  iiue 
chromicized  catgut  prepared  to  resist  absorption  for  twenty  days. 
The  skin  wound  is  sutured  with  fine  black  silk.  Primary  union 
is  striven  for  and  often  obtained ;  but  should  this  not  be  the  case 
the  ultimate  result  of  operation  may  still  be  satisfactory  if  the 
deep  sutures  hold  the  muscular  ends  firmly  together  until  granu- 
lation is  complete.  Hence  the  desirability  of  suturing  the  muscle 
with  a  catgut  which  will  resist  absorption  for  three  weeks. 

The  bowels  should  be  kept  quiet  four  or  five  days.  Oil  in- 
jections should  then  be  administered  and  mild  laxatives.  After 
the  movement  the  parts  should  be  carefully  cleansed. 

This  treatment  by  restoring  the  original  condition  is  the  best 
that  can  be  employed.  Unfortunately  it  is  many  times  inapplica- 
ble, either  because  of  wasting  of  the  sphincter  or  paralysis  of  a 
part  or  the  whole  of  the  muscle  or  on  account  of  the  loss  of  the 
muscle,  as  after  many  cases  of  rectal  resection.  Under  such  cir- 
cumstances attempts  have  been  made  to  establish  continence  by  a 
purse  string  wire  suture  introduced  subcutaneously  and  allowed 
to  remain ;  by  twisting  of  the  rectum  and  suture  in  its  new  rela- 
tions; and  by  other  plastic  operations  described  in  special  text- 
books. 

Much  can  be  done  to  relieve  the  patient  by  keeping  his  stools 
in  a  solid  condition  and  by  washing  out  the  feces  regularly  once 
or  twice  a  day.  If  all  these  measures  are  of  no  avail,  the  question 
of  left  inguinal  colostomy  should  be  considered.  A  continent 
artificial  anus  in  a  situation  where  it  can  be  cared  for  by  the 
patient  is  in  many  respects  better  than  an  incontinent  natural  anus. 

CONGENITAL   DEFORMITIES 

Imperforate  Anus. — The  only  important  malformation  of 
the  anus  or  rectum  is  a  lack  of  communication  of  the  lumen  of  the 
bowel  and  the  outside  world  through  the  anus.     The  lower  bowel 


IMPERFORATE   ANUS  323 

may  terminate  in  the  vagina,  and  normal   defecation  take  place 

in  this  manner  for  years.  There  may  ho  only  a,  minute  opening 
between  the  anus  and  rectum — a  congenital  stricture.  There  may, 
however,  be  no  opening  to  the  bowel,  and  unless  this  condition  is 
relieved  within  a  short  time  after  birth  the  death  of  the  infant 
must  follow.  The  anus  and  the  sphincter  ani  may  or  may  not  be 
normally  present.  If  the  external  structures  are  perfect  and  the 
bowel  reaches  to  within  a  quarter  or  half  an  inch  of  the  skin,  an 
opening  is  easily  made  through  the  septum,  and  the  continuity  of 
the  lumen  is  restored.  If  the  distance  from  the  lower  end  of  the 
rectum  to  the  surface  is  more  than  half  an  inch  it  may  be  difficult 
to  find  the  rectum  at  operation,  and  some  surgeons  consider  colos- 
tomy preferable  to  a  prolonged  attempt  to  find  the  bowel.  One  of 
the  difficulties  of  finding  the  lower  end  of  the  rectum  is  the  fact 
that  instead  of  being  situated  immediately  above  the  imperforate 
anus,  it  is  often  deflected  one  way  or  another,  usually  lying  an- 
terior to  its  normal  situation.  In  these  cases  the  mortality  after 
operation  is  high,  as  it  is  also  after  colostomy  for  imperforate 
anus.  If  merely  a  congenital  stricture  exists,  it  may  be  dilated 
or  divided,  according  to  circumstances.  If  dilation  is  easily  per- 
formed, it  is  preferable,  as  a  wound  is  thereby  avoided. 


SECTION  VI 

AFFECTIONS  OF  THE  ARM  AND  HAND 
(UPPER  EXTREMITY) 


CHAPTER    XIII 

INJURIES    TO    THE    SOFT    PARTS    OF   THE    ARM    AND 

HAND 

The  upper  extremity  is  especially  exposed  to  traumatism. 
Fractures  of  the  various  bones  in  the  arm  and  hand  constitute  a 
large  part  of  all  fractures.  The  proportion  of  slighter  traumatisms 
is  perhaps  larger.  Moreover  so  many  important  structures  lie 
close  to  the  skin  of  this  part  of  the  body  that  a  slight  injury  may 
have  serious  effects.  Familiar  examples  are  an  incised  wound 
of  the  front  of  the  wrist,  opening  the  radial  or  ulnar  artery,  or 
dividing  some  flexor  tendons ;  a  burn  of  the  palm,  producing  per- 
manent flexion  of  the  fingers ;  suppuration  involving  a  tendon 
sheath,  and  preventing  further  motion  of  the  tendon. 

Contusions. — Diagnosis  of  contusion  is  easily  made  from  the 
redness  and  abrasion  of  the  skin,  tenderness  on  pressure,  ecchy- 
mosis,  and  swelling.  If  there  is  loss  of  function,  or  if  manipula- 
tion of  the  underlying  bone  is  painful,  search  should  be  made  for 
a  fracture  or  sprain.  It  may  be  difficult  to  differentiate  a  contu- 
sion involving  a  bone,  from  a  partial  fracture,  or  a  fracture  with- 
out displacement.  Without  the  aid  of  the  X-ray  it  may  be  nec- 
essary to  wait  a  week  or  two,  to  see  if  the  symptoms  of  deep 
tenderness  and  disability  disappear  before  asserting  positively 
that  the  bone  is  uninjured. 

Treatment. — The  treatment  of  simple  contusion  is  given  on 
page  2.  A  sling  is  in  most  cases  advisable.  It  is  less  conspicuous 
if  made  of  a  black  silk  handkerchief  or  a  black  ribbon  two  or  three 
inches  in  width ;  or  if  the  patient's  pride  does  not  permit  even 
this,  he  may  keep  his  hand  between  the  second  and  third  buttons 
of  his  coat. 

324 


HEMATOMA  325 

Contusions  about  the  joints  are  often  associated  with  sprains, 
and  they  are  therefore  discussed  under  that  heading. 

Blister.- — A  blister  is  the  lifting  up  of  the  superficial  portion 
of  the  epidermis  with  serous  or  seropurulent  or  bloody  fluid. 
Blisters  are  common  lesions  in  many  diseases.  They  are  also 
seen  in  burns  and  frost-bites.  They  also  follow  traumatism. 
The  last  is  the  only  type  of  blister  which  will  be  here  consid- 
ered. The  traumatism  may  be  a  slight,  oft  repeated  friction  upon 
skin  unaccustomed  to  it  or  a  sudden  more  severe  traumatism,  usu- 
ally in  the  form  of  the  pinching  of  the  skin.  Blisters  of  the  first 
type  are  common  upon  the  palms  of  the  hand,  from  rowing  a  boat 
or  using  heavy  tools,  and  upon  the  heels  and  toes  as  a  result  of 
an  unusual  amount  of  walking.  Blisters  of  the  second  type  usu- 
ally contain  a  certain  amount  of  blood,  and  are  called  blood-blis- 
ters.    Such  a  blister  is  a  small  hematoma   (v.  infra). 

Treatment. — In  the  treatment  of  a  blister  the  object  is  to 
protect  the  tender  underlying  epithelium  for  a  few  days  until  it 
becomes  harder.  Hence  the  blister  should  not  be  removed,  but  its 
fluid  should  be  withdrawn  by  the  oblique  passage  into  it  of  a 
needle,  which  enters  the  sound  skin  about  an  eighth  of  an  inch 
away  from  the  edge  of  the  blister.  The  skin  should  first  be 
cleansed  with  alcohol,  and  the  needle  passed  through  flame  to 
prevent  infection.  If  the  whole  blister  has  been  torn  away,  the 
underlying  skin  should  be  protected  by  a  wet  dressing  or  a  cotton- 
collodion  dressing  or  a  simple  ointment. 

If  a  blister  contains  pus,  all  of  the  raised  epithelium  should 
be  at  once  cut  away  and  a  wet  antiseptic  dressing  applied. 

Hematoma. — The  description  and  treatment  of  hematoma  of 
the  head  (p.  2)  is  applicable  to  hematoma  of  the  arm.  There 
are,  however,  two  special  forms  of  hematoma  peculiar  to  this 
region. 

Hematoma  Beneath  the  Nail. — If  the  blood  is  poured  out  be- 
neath the  nail,  this  is  wholly  or  partly  lifted  from  its  bed,  and 
even  then  the  unrelieved  pressure  may  cause  the  patient  great 
pain.  As  the  bluish  red  of  the  clotted  blood  shows  through  the 
translucent  nail  the  diagnosis  is  unmistakable  (Fig.  144). 

Treatment  consists  in  cutting  away  a  narrow  transverse  strip 
of  the  nail  near  its  base  to  relieve  the  pressure  and  prevent  sup- 
puration  (Fig.  145).     If  the  base  of  the  formed  nail  has  been 


326    INJURIES   TO   THE   SOFT    PARTS   OF   THE    AliM    AND   HAND 

separated  from  the  matrix,  il  should  be  freed  from  the  overlying 
skin  with  the  poinl  of  a  knife  and  removed.     II   the  whole  nail 


Fig.  144. — Hematoma  Beneath  the  Nail. 
The  skin  is  lifted  by  the  formed  nail,  the 
outline  of  which  is  readily  seen. 


Fig.  145. — Incision  for  Evacu- 
ation of  the  Blood  in  Hem- 
atoma Beneath  the  Nail. 


has  been  loosened,  it  should  be  thus  freed  from  the  skin  and  re- 
moved. In  any  case  a  dressing  should  be  kept  over  the  finger  for 
a  few  days  to  prevent  dirt  from  making  its  way  beneath  the  loos- 
ened nail  and  to  protect  the  tender  bed  of  the  nail. 

Cutaneous  Hematoma  or  Blood-blister. — Small  hematomata  are 
produced  in  the  palmar  skin  by  pinching  or  by  continued  rubbing, 
as  of  an  oar.  They  usually  contain  bloody  serum  and  are  called 
blood-blisters.  The  contents  of  these  blisters  should  be  pressed  out 
through  the  channel  made  by  passing  a  clean  needle  through  sound 
skin  into  the  blister.  This  evacuation  may  have  to  be  repeated 
once  or  twice. 

A  blow  upon  the  olecranon  or  upper  part  of  the  ulna  may  pro- 
duce a  large  hematoma.     The  circulation  in  this  region  is  not  very 


RUPTURE   OF   THE    BICEPS   MUSCLE  327 

active,  and  if  the  skin  is  broken  and  the  wound  neglected  the  hema- 
toma may  suppurate,  oven  when  there  is  no  apparent  connection 
between  the  superficial  wound  and  the  hematoma.  The  treatment 
is  then  that  of  an  abscess   (see  p.  408). 

Rupture  of  the  Biceps  Muscle. — The  biceps  muscle  may 
be  partly  or  completely  torn,  usually  by  an  attempt  to  lift  a  too 
great  weight.  This  accident  occurs  almost  exclusively  in  men,  and 
usually  in  those  who  have  passed  their  prime,  or  in  those  whose 
muscles  have  been  weakened  by  alcoholism  or  disease. 

The  history  given  is  that  of  sudden  pain  in  the  arid  during  a 
strain,  followed  by  muscular  weakness.  If  the  muscle  is  only  par- 
tially torn,  the  patient  is  able  to  flex  his  forearm,  but  with  nothing 
like  the  usual  power. 

Physical  examination  confirms  the  statement  of  the  patient  as 
to  the  loss  of  muscular  power  of  flexion,  especially  when  the  fore- 
arm is  supinated.  Careful  palpation  will  usually  reveal  a  depres- 
sion at  the  site  of  rupture.  This  may  be  in  either  the  tendinous 
or  muscular  portion  of  the  biceps.  Moreover,  when  the  patient 
attempts  to  contract  the  muscle  it  remains  flabby,  although  he 
may  move  it  to  a  certain  extent.  If  only  a  part  of  the  muscle 
or  one ,  of  its  heads  is  ruptured,  this  part  will  remain  flabby 
while  the  remaining  portion  is  firmly  contracted.  Sometimes 
the  retraction  of  the  torn  portion  of  the  muscle  forms  a  notice- 
able bunch. 

Treatment. — The  treatment  may  be  operative  or  non-opera- 
tive. In  young  and  healthy  subjects  the  rupture  in  the  muscle  or 
tendon  should  be  exposed  by  a  longitudinal  incision,  the  torn  ends 
sutured  by  fine  silk  or  fine  catgut  chromatized  to  resist  absorption 
in  the  tissues  for  twenty  days  or  more.  The  skin  should  be  sutured 
without  drainage,  and  the  forearm  kept  in  a  flexed  position  by  a 
broad  sling,  or,  if  the  patient  cannot  be  trusted,  the  arm  should 
be  fixed  in  this  position  by  a  light  gypsum  or  starch  bandage. 
This  should  be  kept  up  for  two  or  three  weeks,  after  which  passive 
motions,  and  later  active  motions,  may  be  resumed. 

If  the  rupture  is  slight,  or  if  the  general  condition  of  the  pa- 
tient makes  an  open  operation  seem  useless,  non-operative  treat- 
ment is  indicated.  The  forearm  should  be  flexed  at  a  riffht  ansde 
and  carried  in  a  sling.  Massage  may  be  employed  every  day  or 
every  second  day,  pressure  being  so  directed  as  to  approximate  the 


328     INJURIES   TO   THE  SOFT   PAETS   OF   THE   ARM    AND    HAM) 

torn  ends  of  the  muscle.  Bandages  or  strips  of  rubber  adhesive 
may  also  be  employed  toward  this  end. 

Wounds. — Punctured  wounds  of  the  hand  or  fingers  rarely 
give  rise  to  troublesome  hemorrhage,  but  they  are  often  followed' 
by  suppuration. 

Bites  of  men  and  animals  should  be  regarded  as  punctured 
wounds,  and  should  receive  the  same  treatment. 

Complications. — Incised  wounds  are  significant  because  un- 
derlying- structures  are  often  injured,  even  though  the  superficial 


Fig.  146. — Position  of  the  Radial  and  Ulnar  Arteries  at  the  Front  of  the 
Wrist.  The  curve  of  the  ulna  toward  the  center  of  the  wrist,  as  it  passes  the 
head  of  the  ulna,  is  often  more  pronounced  than  it  is  here  represented.  Some- 
what diagrammatic. 

wound  is  small.  This  is  especially  true  if  the  instrument  causing 
the  wound  is  very  sharp,  as  a  chisel  or  a  pointed  fragment  of  glass. 
The  possible  complications  of  such  a  wound  are  incision  or  division 
of  an  artery  or  nerve,  or  one  or  more  tendons,  or  the  opening  of 
a  joint.  The  radial  and  ulnar  arteries  are  superficial  in  the  wrist, 
and  are  often  injured.  One  is  wont  to  think  of  the  ulnar  artery 
as  lying  close  to  the  ulnar  side  of  the  forearm,  forgetting-  that  in 
the  wrist  where  this  vessel  is  superficial  it  makes  a  sharp  curve 
toward  the  radial  side  to  clear  the  head  of  the  ulna  and  the  pisi- 


wounds  329 

form  bone  (see  Fig.  146).  Hence  it  is  often  opened  in  transverse 
cuts,  which  are,  roughly  speaking,  in  the  middle  of  the  wrist. 

The  ulnar  nerve  may  be  cut  at  the  elbow  between  the  inner 
condyle  of  the  humerus  and  the  olecranon.  This  produces  paral- 
ysis of  the  flexor  carpi  ulnaris,  inability  to  separate  the  fingers, 
loss  of  sensation  of  the  outer  half  of  the  ring  finger  and  of  the 
little  finger  in  front  and  behind.  Division  of  the  ulnar  nerve  at 
the  wrist  gives  the  same  symptoms  in  the  hand. 

If  the  radial  nerve  is  divided  at  the  wrist,  sensation  is  lost  in 
the  back  of  the  thumb  and  index-finger.  There  is  no  muscular 
paralysis. 

If  the  median  nerve  is  divided  at  the  wrist  its  muscular 
branches  to  the  flexors  of  the  forearm  are,  of  course,  not  affected. 
There  will  be  inability  to  abduct  the  thumb  and  loss  of  sensation 
in  the  palmar  surface  of  the  thumb  and  index-finger. 

The  symptoms  here  given  are  not  all  the  changes  which  fol- 
low these  nerve  injuries,  but  they  are  the  most  striking  ones 
and  are  sufficient  for  diagnosis.  It  is  best  to  disregard  sensa- 
tion in  the  middle  finger,  as  anastomosis  may  give  misleading 
symptoms. 

The  tendons  most  often  divided  in  wounds  of  the  arm  are  those 
of  the  muscles  which  have  their  origin  in  the  forearm  and  their 
insertion  in  the  hand.  Twenty-three  such  tendons  pass  through 
the  annular  ligament.  They  may  be  cut  either  in  the  wrist,  hand, 
or  fingers.  Most  of  them  are  easily  palpated  when  put  on  the 
stretch  by  resisted  voluntary  motion,  and  a  comparison  with  the 
other  hand  will  usually  show  whether  any  one  of  them  is  divided ; 
but  if  in  doubt,  the  medical  attendant  will  do  well  to  postpone 
suture  of  the  wound  in  the  skin  until  he  has  refreshed  his  anatom- 
ical memory. 

The  action  of  the  deep  and  superficial  flexors  of  the  fingers 
may  be  distinguished  as  follows:  If  both  are  divided,  the  finger 
cannot  be  flexed  with  any  considerable  force.  The  lumbricales 
and  interossei  have  only  a  feeble  action  as  compared  with  the  nor- 
mal flexors.  If  the  tendon  of  the  flexor  profundus  to  any  finger  is 
divided,  the  patient  cannot  flex  the  terminal  phalanx  when  the  sec- 
ond phalanx  is  held  extended  by  the  surgeon  (Fig.  147).  If  the 
tendon  of  the  sublimis  is  divided,  the  patient  cannot  flex  the  sec- 
ond phalanx  when  the  first  is  held  extended,  or  at  least  not  until 


330     INJURIES    TO    THE   SOFT    PARTS    OF   THE    ARM    AND    HAND 


Fig.  147. — Test  for  Division  of  the  Profundus  Ten- 
don. When  the  second  phalanx  is  held  extended  the 
terminal  phalanx  cannot  be  flexed  voluntarily  if  the 
profundus  is  divided 


after  the  third  has 
been  well  flexed  on 
the  second.  With 
division  of  the  sub- 
limis, the.  test  posi- 
tion  shown  in  Fig- 
ure 148  cannot  be 
assumed. 

Joints  of  the 
arm  and  hand  arc 
most  exposed  to  in- 
cision on  their  pos- 
terior aspect.  The 
metacarpo  -  phalan- 
geal joints  are 
opened  far  more 
frequently  than  the 
others. 

Treatment. — 
The  treatment  of 
wounds  of  the  arm 
and  hand  consists 
in  the  removal  of 
any  dirt,  the  con- 
trol of  hemorrhage, 
the  approximation 
of  the  tissues  by 
suture  if  necessary, 
and  a  dry  dressing, 
or,  if  the  cleansing 
is  doubtful,  a  wet 
dressing.  (For  the 
details  of  such 
treatment  see  p. 
13.)  The  skin  of 
the  hand  or  finger 
should  not  be  cut 
away  simply  to  obtain  a  straight  line  of  suture.  It  is  well  sup- 
plied with  blood,  and  heals  rapidly. 


Fig.  148. — Test  for  Division  of  the  Sublimis  Ten- 
don. When  the  first  phalanx  is  held  extended,  the 
patient  cannot  flex  the  second;  certainly  not  until  the 
terminal  phalanx  has  been  flexed — in  cases  of  division 
of  the  sublimis. 


WOUNDS  331 


If  a  portion  of  skin  has  been  destroyed  in  such  a  manner  that 
the  edges  of  the  wound  cannot  be  sutured,  an  ulcer  will  result. 
If  this  is  so  shallow  that  islands  of  epithelium  are  left  in  its  base 
it  will  quickly  become  covered  with  new  skin.     If  the  whole  thick- 


Fig.  149. — Traumatic  Ulcers  of  the  Hand;  Duration  Seventeen  Days;  Active 
Granulations.     In  good  condition  for  skin-grafting.      Patient  aged  fifty  j'ears. 

ness  of  skin  is  destroyed,  the  gap  should  be  covered  with  skin 
grafts  if  it  is  more  than  one  inch  in  diameter.  The  diameter  of 
an  ulcer  left  to  close  by  marginal  growth  will  diminish  only  by 
about  one-quarter  of  an  inch  a  week,  and  the  epithelium  in  a  large 
scar  thus  produced  is  inferior  to  that  of  a  Thiersch  graft.  The 
grafts  may  be  applied  to  a  fresh  wound,  after  it  has  been  cleansed 
and  the  hemorrhage  stopped,  or  to  the  resulting  ulcer,  when  its 
base  is  thickly  covered  with  granulations  (Fig.  149). 

Treatment  of  Minute  Wounds  of  the  Fingers. — A  pin-prick  or 
other  wound  of  the  finger  or  hand,  insignificant  in  itself,  may  yet 


332     INJURIES   TO   THE   SOFT   PARTS   OF   THE   ARM    AND   HAND 

be  the  starting-point  of  a  serious  inflammation.  Indeed,  most  of 
the  suppurations  of  the  upper  extremity  begin  in  such  minute 
wounds.  Their  proper  treatment  is,  therefore,  a  matter  of  no 
small  importance.  Probably  no  method  of  treatment  can  afford 
infallible  protection  from  infection,  but  in  a  rather  extensive  ex- 
perience with  this  class  of  wounds  the  author  has  never  known 
infection  to  extend  beyond  the  immediate  area  of  the  wound,  and 
rarely  to  manifest  itself  even  there  when  the  following  rules  have 
been  observed : 

1.  Make  the  wound  bleed  promptly  by  pinching  it,  sucking  it, 
and,  if  necessary,  enlarging  it. 

2.  Cleanse  the  adjacent  skin  by  vigorous  scrubbing  with  strong 
antiseptics,  such  as  turpentine,  ether,  or  bichlorid  solution. 

3.  Shave  away  any  surplus  dead  epithelium. 

4.  Apply  a  wet  antiseptic  dressing  for  a  few  hours. 

5.  If  the  wound  contains  visible  foreign  material,  e.  g.,  rotten 
wood  from  a  splinter,  or  has  been  made  by  something  probably 
covered,  with  pyogenic  germs,  e.  g.,  an  old  fish-bone,  it  should  be 
laid  open  and  drained  if  its  track  can  be  followed. 

6.  The  wound  should  be  inspected  on  the  following  day,  and 
if  it  is  indurated  and  tender,  an  incision  should  be  made  through 
the  indurated  area  only.     A  minute  drop  of  pus  may  escape. 

Ligation  of  Vessels. — If  a  wound  has  opened  a  vessel  of 
sufficient  size  to  require  ligation,  the  incision,  if  such  is  necessary, 
should  be  made  in  the  long  axis  of  the  limb,  even  though  this 
makes  an  irregular  wound.  Before  the  vessel  is  tied  with  No.  1 
or  JSTo.  2  catgut  it  should  be  entirely  isolated,  so  that  no  nerve 
may  be  included  in  the  ligature.  A  local  anesthetic  is  satisfac- 
tory, but  some  patients  prefer  a  general  one  in  order  to  avoid  the 
nervous  shock.  Suture  of  the  skin  with  horsehair  or  fine  black 
silk,  and  a  dry  dressing,  together  with  a  splint  and  sling  if  the 
wound  is  serious,  complete  the  treatment. 

Suture  of  Tendons. — A  recently  divided  tendon  should  be 
sutured  with  fine  chromic  catgut  (No.  0  or  1).  Some  surgeons  pre- 
fer fine  silk,  believing  that  the  catgut  makes  a  rougher  suture  and 
may  be  absorbed  before  the  ends  of  the  tendon  have  firmly  united. 
The  sheath  should  then  be  sutured  with  plain  catgut.  The  skin 
wound  should  be  closed  entirely,  or  with  drainage  if  infection  is 
feared,  and  the  part  bandaged  in  such  a  position  that  the  sutured 


SUTURE  OF  TENDONS  333 

tendon  shall  be  relaxed.  It  is  well  to  begin  passive  motions  in  a 
week  or  ten  days,  to  prevent  adhesions  between  the  tendon  and 
its  sheath.  Active  motions,  very  gentle  at  first,  should  be  begun 
within  two  weeks  of  the  suture. 

If  the  ends  of  the  tendon  come  together  without  tension  a 
simple  stitch  will  suffice  (Fig.  150  B).     If  the  proximal  part  has 


Fig.   150. — Tendon   Sutube.      A,  Mattress        Fig.    151. — Tendon    Suture.      One 
stitch  ;  B,  simple   stitch,  more  likely  to  method  of  elongation  to  fill  a  gap 

cut  out  than  a  mattress  stitch.  between  the  ends.    There  are  many 

other  methods. 

retracted  so  that  the  stitch  is  likely  to  be  pulled  upon,  a  mattress 
stitch  is  better,  as  less  likely  to  cut  out  (Fig.  150  A ) .  Both  stitches 
should  be  passed  with  a  fine  needle  about  one-quarter  of  an  inch 
from  the  cut  end  of  the  tendon.  If  the  gap  between  the  ends  is 
too  great  to  permit  of  direct  suture,  one  or  both  ends  of  the  ten- 
don may  be  elongated,  as  shown  in  Figure  151.  This  method  is 
at  best  a  clumsy  one,  and  as  it  necessitates  splitting  the  tendon 
sheath  for  a  considerable  distance,  operators  have  been  searching 
for  a  better  method. 


;;;;!    [njuries  to  the  soft  parts  of  the  arm  and  hand 


Another  way  of  overcoming  n  gap  in  a  tendon  due  to  retrac- 
tion, or  due  to  sloughing  of  the  tendon  from  suppuration  in  its 

sheath,  is  to  unite  the  separated  ends  by  a  long  silk  stitch,  making 
no  attempt  to  bring  the  ends  of  the  tendon  together,  but  leaving 
the  thread  to  act  as  a  part  of  the  tendon  (Fig.  L52).  The  silk, 
like  all  aseptic  foreign  bodies  of  small  size,  becomes  encased  with 
fibrous  tissue,  and  if  the  patient  persists  in  passive  and  active 
motions  as  soon  as  the  skin  has  healed,  more  or  less  use  of  an 
otherwise  totally  helpless  finger  will  result.     The  reports  in   the 

lew  eases  in  which  this  method  has 
been  tried  indicate  that  it  is  far  supe- 
rior to  the  splitting  and  elongation 
of  the  tendon  itself.  It  is  easy  to 
split  a  recently  divided  tendon,  but 
in  the  course  of  weeks  or  months  the 
ends  often  atrophy  so  that  there  is 
is  scarcely  enough  left  to  be  recog- 
nized. On  the  other  hand,  nature  is 
capable  of  filling  a  gap  in  a  tendon 
if  the  sheath  has  not  been  closed  by 
inflammation  and  if  the  ends  are  not 
constantly  pulled  apart  by  muscular 
action. 

Suture  of  Nerves.- — If  a  nerve 
is  divided  in  a  recent  wound  it  should 
be  at  once  sutured  with  very  fine  cat- 
gut or  with  silk.  Three  or  four  sim- 
ple sutures  should  be  inserted  in  the 
sheath  of  the  nerve  (Fig.  153).  The 
skin  should  be  sutured  and  the  arm 
kept  for  two  or  three  weeks  in  such 
a  position  that  the  nerve  is  relaxed. 


Fig.  152. — Tendon  Suture.  A 
long  silk  stitch  left  in  place  to 
act  as  a  tendon.  Tt  becomes 
covered  with  fibrous  tissue 
growing  out  from  the  cut  ends 
of  the  tendon. 


Motions  should  then  be  gradually  re- 


sumed. It  takes  from  three  to  nine 
months  to  restore  function  in  a  di- 
vided nerve.  Sensation  is  usually  re- 
stored   before   motion.      During   this 

period  the  condition  of  the  muscles  supplied  by  the  nerve  should 

be  kept  good  by  massage  and  electricity. 


WOUNDS   OF   JOINTS 


335 


If  the  division  of  a  nerve  is  an  old  one,  its  fibers  have  prob- 
ably so  degenerated  that  repair  is  out  of  the  question. 

If  the  divided  nerve  has  retracted,  or  if  a  part  of  if-  has  been 
destroyed,  it  may  be  split  and  turned  down.  The.  operation  is 
similar  to  that  upon  a  tendon  (Fig.  151).  This  operation  is  still 
in  the  experimental  stage. 

If  a  nerve  is  injured  by  a  blow,  or  by 
continued  pressure,  loss  of  sensation  and  of 
motion  may  follow.  If  the  paralysis  is  to- 
tal, and  shows  no  signs  of  disappearing  in  a 
few  days,  the  essential  part  of  the  nerve  is 
probably  divided.  If  so,  the  reaction  of  de- 
generation in  the  muscles  supplied  by  it  will 
appear  in  about  fourteen  days.  The  nerve 
should  be  exposed,  ragged  ends  trimmed  off, 
and  sutures  inserted.  A  contusion  of  a 
nerve  may  give  a  partial  or  complete  paral- 
ysis, but  its  activity  will  gradually  return, 
until  after  some  weeks  or  months  there  is 
a  complete  restoration  of  function.  This 
should  be  aided  by  exercise,  massage,  and 
electricity.  This  accident  frequently  fol- 
lows prolonged  anesthesia  if  the  patient's 
arm  is  allowed  to  rest  on  the  edge  of  the 
table  (musculospiral),  or  if  the  arms  are 
too  tightly  held  over  the  head  (brachial 
plexus). 

Wounds  of  Joints. — A  punctured  or 
incised  wound  may  open  a  joint.  Tnis  acci- 
dent is  very  important  because  of  the  infec- 
tion which  may  follow,  and  may  destroy  the  function  of  the  joint. 
Under  such  circumstances  the  opening  in  the  joint  capsule  should 
not  be  sutured  entirely,  but  enough  space  should  be  left  for  drain- 
age. The  skin  suture  should  allow  a  small  wick  of  rubber  tissue 
to  extend  to  the  opening  in  the  capsule.  Either  a  dry  or  wet 
dressing  may  be  used. 

If  manifest  impurities  have  entered  the  joint  the  opening  in 
it  should  be  so  enlarged  that  free  irrigation  with  sterile  normal 
saline  solution  is  possible.     The  drain  of  rubber  tissue  should  in 


Fig.  153. — Suture  of 
Nerve.  The  needle 
should  be  passed 
through  the  sheath 
only. 


330     INJURIES   TO   THE   SOFT   TARTS   OF  THE   ARM    VXD   HAND 

this  case  extend  through  the  capsule  of  the  joint  This  drain 
should  be  withdrawn  from  the  joinl  in  twenty-four  hours  if  there 

are  no  signs  of  increasing  inllammation.  A  wet  dressing  should 
be  employed. 

In  both  classes  of  cases  the  joint  should  be  immobilized  by  a 
splint  applied,  when  possible,  to  the  opposite  side  of  the  limb.  The 
drain  through  the  skin  should  be  left  in  place  two  or  more 
days,  until  it  is  evident  that  no  move  fluid  is  coming  from  the 
joint. 

If  the  joint  suppurates,  the  treatment  is  that  given  on  page  !  25. 

Foreign  Bodies. — Splinters  of  wood,  bits  of  glass,  and  parts 
of  needles  are  the  objects  commonly  fonnd  in  wounds  of  the  hand 
and  arm.     Bullets  and  shot  are  less  common. 

There  is  a  popular  belief  that  certain  objects  are  especially 
likely  to  produce  a  suppurating  wound.  Brass  filings  and  the 
slivers  of  yellow  pine  have  this  bad  reputation.  The  former  are 
often  covered  with  grease  or  oil.  The  latter,  on  account  of  their 
strength  and  sharpness,  penetrate  more  deeply  than  the  ordinary 
splinter.  Splinters  usually  lie  obliquely.  A  small  deeply  placed 
splinter  of  new  wood  may  become  encysted  like  a  piece  of  glass, 
and  give  the  same  symptoms. 

Fragments  of  glass  are  often  left  in  an  incised  wound  because 
the  physician  is  careless  in  inspecting  so  clean  a  wound,  or  be- 
cause the  transparent  glass  is  not  easily  seen.  Such  wounds  do 
not  usually  suppurate,  and  they  often  heal  primarily.  If  a  bit 
of  glass  is  left  in  the  wound  it  becomes  surrounded  by  scar  tissue, 
and  may  not  be  noticed  until  the  main  scar  has  atrophied.  Then 
it  is  revealed  as  a  hard  object  in  or  beneath  the  skin,  giving  a 
slight  sharp  pain  when  pressed  upon  or  when  certain  motions  are 
made.  If  the  examiner  cannot  feel  the  foreign  body  distinctly, 
and  if  he  does  not  cause  pain  every  time  he  makes  a  certain  pres- 
sure, he  will  do  well  to  postpone  operation  until  more  definite 
symptoms  are  present  or  until  a  radiograph  shows  the  exact  situa- 
tion of  the  object.  Sometimes  a  patient,  feeling  pain  in  a  scar, 
attributes  it  to  the  presence  of  a  foreign  body,  although  it  is  really 
due  to  pressure  of  the  scar  upon  some  nerve-fibers. 

A  needle  is  often  driven  into  the  hand  or  forearm  while  the 
patient  is  scrubbing,  or  dusting  a  curtain.  The  needle  is  broken, 
and  the  doctor  is  consulted  if  it  breaks  below  the  surface  of  the 


FOREIGN   BODIES  337 

skin.  Sometimes  the  end  is  in  plain  sight,  or  it  can  be  felt  just 
beneath  the  skin.  Those  cases  are  more  difficult  in.  which  the  pa- 
tient received  a  punctured  wound  supposed  to  be  due  to  a  needle, 
although  no  needle  was  seen.  There  is  pain  on  making  certain 
motions,  and  pressure  causes  pain.  These  symptoms  indicate  that 
a  fragment  of  needle,  perhaps  less  than  half  an  inch  long,  is  buried 
in  the  tissues.  A  search  for  it  without  more  definite  knowledge 
of  its  situation  is  rarely  successful.  One  should  resort  to  a  fluoro- 
scopic examination  or,  better  still,  radiographs  should  be  taken  in 
two  planes. 

Bullets  and  shot  may  be  touched  with  a  probe  passed  through 
the  wound  of  entrance  and  so  diagnosticated.  If  this  is  not  pos- 
sible they  should  be  located  by  means  of  the  X-ray. 

The  fate  of  a  foreign  body  embedded  in  the  tissues  depends 
partly  upon  its  nature  and  partly  upon  the  entrance  with  it  of 
pathogenic  organisms.  Most  foreign  bodies  are  capable  of  resist- 
ing disintegration  in  the  tissues  for  an  indefinite  time.  They  will, 
therefore,  either  become  encysted  or  produce  a  suppuration  and  a 
sinus,  through  which,  sooner  or  later,  they  will  be  expelled  from 
the  body.  Powder  grains  and  the  ink  of  the  tattooer  are  familiar 
examples  of  the  first  class.  Needles  and  splinters  of  glass,  being 
practically  free  from  germs,  are  frequently  included  in  an  aseptic 
scar.  Splinters  of  rotten  wood,  fish-bones,  greasy  metal  filings, 
etc.,  are  almost  always  cast  out  by  the  suppuration. 

Treatment. — The  treatment  in  all  these  cases  should  be  to 
enlarge  the  wound  of  entrance  sufficiently  to  render  certain  the 
removal  of  the  foreign  body  and  to  provide  for  drainage.  The 
skin,  if  grimy,  and  the  wound  should  be  thoroughly  scrubbed  with 
soap,  turpentine,  and  ether.  In  cleaner  cases,  soap  and  hot  water, 
followed  by  alcohol  or  an  antiseptic  solution,  will  suffice.  It  is 
well  to  reduce  the  pain  as  much  as  possible  by  the  use  of  a  local 
anesthetic.  A  splinter  usually  enters  the  skin  obliquely ;  therefore 
the  incision  should  be  so  made  as  to  expose  the  whole  splinter,  in 
case  the  wood  is  rotten.  With  new  wood  a  short  incision  may 
suffice. 

If  the  wound  has  been  caused  by  glass,  its  edges  should  be 
fully  retracted,  so  that  no  portions  of  the  glass  shall  be  overlooked. 
These  wounds  are  often  oblique,  or  even  irregular,  due  to  the  con- 
traction of  the  muscles  at  the  time  the  accident  occurs.     Hence 


338    INJURIES  TO   THE  SOFT   PARTS   OF  THE  ARM  AND   HAND 

there  is  a  greater  necessity  for  a  thorough  exposure,  even  though 
the  wound  in  the  skin  has  to  be  made  larger. 

A  portion  of  a  needle  is  often  a  difficult  foreign  body  to  locate. 
If  the  needle  appears  in  the  wound,  it  can  be  grasped  with  forceps 
and  extracted.  If  one  end  of  the  fragment  is  felt  just  beneath  the 
skin,  its  removal  is  likewise  simple.  In  many  cases,  however,  it 
can  neither  be  seen  nor  felt  by  the  doctor,  although  the  patient  is 
certain  of  its  presence.  In  these  cases  plenty  of  time  should  be 
given  to  determine  the  exact  location  of  the  needle  before  the 
search  for  it  is  made  with  a  knife.  The  best  single  guide  to  its 
position  is  the  sensation  of  the  patient  when  pressure  is  made  upon 
the  tissues  in  which  the  needle  is  embedded.  The  operator  should 
make  the  most  of  this  before  administering  a  general  anesthetic. 
Even  after  a  local  anesthetic  this  sensation  may  be  lost.  Incision 
for  search  has  to  be  made  in  the  long  axis  of  the  limb,  and  yet  it 
is  desirable  to  so  direct  the  plane  of  incision,  if  possible,  that  the 
needle  shall  lie  across  it. 

A  bullet  is  often  more  readily  reached  through  an  incision 
made  somewhere  else  than  at  the  wound  of  entrance. 

The  decision  to  suture  the  wound,  or  to  drain  it,  must  rest 
upon  the  probability  of  infection.  In  doubtful  cases  it  is  well  to 
suture  the  wound  and  to  drain  it  with  flat  gutta-percha  drains, 
which  can  readily  be  extracted  in  a  few  days,  if  there  is  then  no 
sign  of  suppuration.  In  this  manner  the  healing  of  the  wyound  is 
scarcely  interfered  with. 

If  there  is  a  possibility  th«it  all  of  the  foreign  material  has 
not  been  removed,  a  drain  should  be  employed  to  facilitate  the 
casting  out  of  small  fragments  or  the  extraction  of  larger  ones. 

Sprain. — A  sprain  is  an  injury  of  the  joint  caused  either  by 
a  too  great  strain  upon  some  ligament  or  by  crowding  together 
the  bones  of  the  joint.  It  will  be  seen,  therefore,  that  the  lesions 
produced  may  be  either  a  rupture  of  some  of  the  ligamentous 
fibers  or  a  separation  of  the  same  from  their  bony  attachments ; 
or,  on  the  other  hand,  a  contusion  of  the  cartilaginous  end  of  one 
or  both  bones.  Often  these  different  lesions  are  associated.  They 
can  usually  be  differentiated  by  carefully  pressing  the  ends  of 
the  bones  together  and  by  drawing  them  apart,  and  by  overflexing 
and  overextending  the  joint.  If  the  bones  are  contused,  pain  will 
be  excited  when  they  are  pressed  together.     If  the  ligamentous 


SPRAIN  339 

fibers  are  broken,  or  have  been  pulled  from  the  bone  to  which 
they  were  attached,  pain  will  be  excited  when  the  ligament  of 
which  they  are  a  part  is  put  upon  the  stretch.  Besides  these 
symptoms,  there  will  be  noted  a  certain  amount  of  swelling,  dis- 
ability, and  pain  without  manipulation  according  to  the  severity 
of  the  injury.     There  is  sometimes  effusion  of  serum  or  blood  into 


Fig.   154. — Sprain  of  Finger  with  Serous  Effusion  in  Joint. 

the  overlying  soft  parts ;  but  in  general  the  ecchymosis  caused  by 
a  sprain  is  far  less  than  that  caused  by  a  fracture.  There  is  often  a 
considerable  effusion  of  serum  into  the  cavity  of  the  joint,  increas- 
ing the  swelling,  and  giving  rise  to  fluctuation  if  the  capsule  of 
the  joint  is  accessible  to  palpation  (Fig.  154). 

Treatment. — -The  treatment  of  a  sprain  is  threefold:  To 
prevent  strain  upon  the  injured  ligaments ;  to  facilitate  the  absorp- 
tion of  the  exudate ;  to  prevent  adhesions  and  stiffness  of  the  joint. 
The  first  indication  is  met  by  a  splint  which  shall  hold  the  joint 
in  a  position  most  comfortable  for  the  patient.  Such  a  position 
is  usually  between  flexion  and  extension.  The  second  object  of 
treatment  is  accomplished  by  massage  and  passive  motion.  Light 
rubbing  of  the  joint  should  be  begun  either  immediately  or  after 
a  day  or  two,  according  to  the  severity  of  the  lesion.  Passive 
motion  is  next  in  order  of  application.  Active  motion  should  be 
delayed  in  severe  cases  for  a  few  days  in  order  to  give  the  acute 
symptoms  time  to  subside.  It  is,  however,  the  best  means  at  our 
command  to  prevent  adhesions  in  a  joint. 

A  dressing  which  fulfils  very  well  the  first  and  second  indi- 
cations and  allows  active  motions  to  a  safe  limited  extent  consists 
24 


340     [NJURIES   TO  THE   SOFT   TARTS   OF  THE   ARM    AM)   HAND 

of  strips  of  rubber  plaster  from  half  an  inch  to  an  inch  in  width, 
put  ou  alternately  from  right  to  left  and  from  left  to  right,  so 
that  they  shall  cross  each  other  at  nearly  a  right  angle.  In  this 
manner  irregnlarities  in  outline  of  the  part  may  be  smoothly  cov- 
ered (Fig.  155).     If  the  wrist  joint  or  one  of  the  intorphnlangeal 


Fig.  155. — Adhesive  Plaster  Strapping   for  Sprain  of  the  Metacarpo- 
phalangeal Joint.     Drawn  from  a  photograph. 

joints  is  sprained,  the  strip  of  plaster  may  be  wound  directly 
around  the  part. 

If  this  dressing  causes  venous  congestion,  it  may  be  slit  longi- 
tudinally on  the  side  opposite  the  sprain.  In  case  of  the  larger 
joints  it  is  only  necessary  to  apply  the  strips  through  two-thirds 
of  the  circumference  of  the  limb. 

Sprain  of  the  Shoulder  (Subdeltoid  Bursitis). — A  common  in- 
jury of  the  shoulder  is  partly  a  contusion,  partly  a  sprain.  It  fol- 
lows falls  either  upon  the  hand  or  upon  the  shoulder  itself,  and 
sometimes  the  effects  of  exposure  are  added  to  those  of  the  trau- 
matism. This  condition  of  the  shoulder  is  in  some  cases  associ- 
ated with  neuritis,  and  in  others  is  accompanied  by  a  paralysis 
due  to  overstretching  or  pressure  upon  some  part  of  the  brachial 
plexus  or  of  the  circumflex  nerve.  Paralysis  of  the  affected  mus- 
cles then  becomes  a  prominent  symptom. 

Anatomically  it  is  to  be  noticed  that  the  shoulder  is  more 
thoroughly  covered  with  muscular  tissue  than  any  other  joint  in 
the  body.      The  large  muscles  about  the  hip-joint  do  not  overlie 


SPRAIN  341 

the  great  trochanter,  and  are  therefore  not  likely  to  he  injured 
by  direct  falls  upon  the  hip;  while  the  joint  itself  is  so  firm  that 
sprains  are  not  likely  to  follow  indirect  violence.  On  the  other 
hand,  lax  joints,  such  as  the  wrist,  are  constantly  exposed  to  vio- 
lence, both  by  direct  blow  and  by  sudden  overstretching,  but  there 
is  no  muscular  tissue  in  the  vicinity  to  be  injured.  The  shoulder- 
joint  then  is  peculiar  in  its  muscular  covering;  and  while  the  joint 
itself  is  so  freely  movable  that  it  is  not  likely  to  suffer  from  over- 
stretching, the  muscular  and  fibrous  planes  and  bursa?  and  nerves 
about  it  are  exposed  to  injury  either  from  overstretching  or  from 
a  direct  blow. 

Diagnosis. — A  patient  who  has  injured  his  shoulder  by  fall- 
ing on  the  hand,  or  on  the  shoulder  itself,  either  presents  him- 
self within  a  day  or  two  after  the  accident  on  account  of  the 
pain  and  disability,  or  else  he  seeks  advice  in  a  week  or  two 
because  improvement  under  home  remedies  has  been  so  slow 
that  he  fears  that  the  injury  is  more  serious  than  he  at  first 
supposed. 

Examination  of  the  shoulder  after  all  clothing  has  been  re- 
moved from  both  shoulders  and  arms  shows  an  absence  of  bony 
deformity ;  and  only  a  slight  swelling  over  the  head  of  the  humerus 
anteriorly  and  exteriorly.  Direct  pressure  is  not  painful,  nor  is 
pressure  made  upon  the  elbow  in  such  a  manner  as  to  crowd  the 
head  of  the  humerus  against  the  scapula.  Both  active  and  passive 
motions  are  limited  by  pain,  and  usually  to  about  the  same  extent. 
Internal  rotation  is  not  very  painful,  and  the  patient  can  often 
put  his  hand  behind  his  back.  External  rotation  and  abduction 
cause  pain  in  the  anterior  portion  of  the  deltoid  muscle.  If  the 
elbow  is  fixed  at  the  side  and  the  forearm  flexed  at  a  right  angle, 
the  patient  may  be  able  to  rotate  the  arm  outward  sufficiently  to 
bring  the  hand  directly  forward,  though  even  this  is  usually  quite 
painful.  If  asked  to  abduct  the  arm,  the  patient  raises  the  scap- 
ula and  humerus  together,  not  changing  the  angle  between  them. 
He  cannot  usually  raise  his  hand  as  high  as  the  top  of  his  head. 
When  the  elbow  is  at  the  side  it  can  be  pushed  backward  with  far 
less  pain  than  it  can  be  pushed  forward.  In  other  words,  the 
lesion  seems  to  be  located  in  the  anterior  portion  of  the  deltoid 
muscle,  or  immediately  beneath  it,  since  contraction  of  this  muscle 
or  passive  motion  of  the  arm  made  in  such  a  manner  as  to  stretch 


342   injuries  to  nn:  soft  Parts  of  the  aiim  and  hand 

it  over  the  head  of  the  bone  causes  pain.  Oilier  signs  of  inflam- 
mation are  wanting. 

If  two  weeks  or  more  have  elapsed  since  the  accident,  there 
will  be  noticed  the  additional  symptom  of  atrophy  of  the  deltoid, 
apparently  from  disuse,  and  the  humerus  will  stand  ont  more 
prominently  on  the  affected  side,  so  that  without  a  careful  exami- 
nation one  might  think  some  bony  deformity  was  present.  Such 
an  accident  occurring  to  a  patient  who  is  a  regular  whisky  drinker 
is  usually  sutluient  to  produce  a  neuritis  of  the  circumflex  nerve. 

Xeuritis  of  the  shoulder  or  arm,  whether  alcoholic  or  other- 
wise, may  occur  withoiit  traumatism.  The  pain  then  exists  when 
the  limb  is  at  rest  as  well  as  when  it  is  moved.  The  pain,  too,  will 
probably  not  be  limited  to  so  small  an  area.  Acute  articular  rheu- 
matism, gonorrheal  arthritis,  suppurative  arthritis,  tuberculosis, 
and  syphilis  of  this  joint  all  have  such  marked  symptoms  due  to 
temporary  or  permanent  derangement  of  the  joint  that  they  can 
hardly  be  mistaken  for  simple  sprain. 

The  effects  of  sprain  last  for  some  weeks  or  months,  and  in 
the  alcoholic,  "  rheumatic,"  old,  and  neglected,  complete  use  of  the 
joint  may  never  be  regained. 

Treatment. — The  best  -treatment  for  sprain  of  the  shoulder 
is  bathing  the  shoulder  twice  a  day  with  very  hot  water,  follow- 
ing this  with  vigorous  rubbing.  Two  or  three  times  a  week  the 
surgeon  or  some  other  responsible  person  should  perform  abduc- 
tion and  external  rotation  of  the  arm,  as  fully  as  the  patient  can 
bear  it,  to  prevent  permanent  limitation  of  motion.  The  patient 
himself  should  make  full  active  motions  of  the  joint  several  times 
a  day.     Counter-irritation  may  be  required  to  allay  pain. 

Neuritis.  - — Neuritis  of  the  arm  occurs  spontaneously,  or  from 
exposure  to  cold,  or  as  a  complication  of  sprain  and  other  injuries. 
Long  rides  in  automobiles  is  a  fruitful  cause  of  neuritis,  espe- 
cially in  those  unaccustomed  to  severe  muscular  exercise.  If  the 
history  of  the  attack  is  confusing  a  differential  diagnosis  can  usu- 
ally be  made  by  the  existence  of  pain  along  the  nerve  trunks 
and  their  branches,  when  the  arm  is  at  rest  as  well  as  when  it  is 
moved.  Sometimes  paralysis,  complete  or  partial,  is  the  striking 
symptom.  This  is  the  case  when  the  brachial  plexus  is  injured 
by  too  violent  attempts  to  reduce  a  dislocation  of  the  shoulder; 
or  by  prolonged  elevation  of  the  arms  above  the  head  in  sleep 


ACUTJO    NON  SUITURATJ  VJ<;   TKNOSYKOVITJS 


343 


or  anesthesia;  or  when  the  musculospinal  is  caught  and  pressed 
upon  by  the  callus  in  fracture  of  the  shaft  of  the  humerus. 

The  local  treatment  of  neuritis  consists  in  the  application 
of  heat  or  cold  or  counter-irritants  to  relieve  pain  and  improve 
local  circulation,  with  rest  of  the  affected  parts.  Later  bathing, 
massage,  and  electricity  are  beneficial,  and  still  later  active  motion. 
It  is  in  these  cases  that  the  daily  use  of  a  mechanical  vibrator 
proves  very  satisfactory.  If  there  is  continued  pressure  upon  the 
nerve,  as  from  a  broken  bone  or  callus,  this  should  be  removed 
early.  If  there  is  reason  to  think  that  the  nerve  may  have 
been  ruptured,  it  should  be  exposed  for  suture.  In  most  cases 
occasional  passive  motions  should  be  made  from  the  first,  to 
prevent  the  formation  of  adhesions,  limiting  the  free  motions  of 
the  joints. 

Acute  Non-suppurative  Tenosynovitis. — This  cumber- 
some title  is  used  to  indicate  a  condition  which  a  traumatism 
may  produce  in '  any  tendon  sheath,  but  which  is  most  common 
in  those  of  the  extensor  tendons  of  the  thumb  and  radial  side  of 


Fig.  156. — Diagram  of  the  Back  of  the  Right  Wrist  to  Show  the  Relations 
of  the  Tendons  to  the  Radius  and  to  One  Another.  Note  that  the  ten- 
dons of  the  extensor  carpi  radialis  longus  and  brevis  lie  between  the  tendons  of 
the  extensors  of  the  thumb  and  the  shaft  of  the  radius.  When  in  violent  action 
each  pair  saws  on  the  other,  and  also  on  the  bone. 

the  hand.  It  is  marked  by  tenderness  and  swelling,  and  a  peculiar 
fine  crepitus  or  creaking  which  is  due  apparently  to  a  loss  of  polish 
of  the  tendons  and  inner  lining  of  the  synovial  sheaths,  espe- 
cially where  they  lie  close  to  the  radius  about  two  inches  above 
the  plane  of  the  joint  (Fig.  156).     The  slightest  motion  of  the 


344     INJURIES   TO   THE   SOFT   PARTS    OF    THE    ARM    AND    HAND 

thumb  or  hand,  whether  active  or  passive,  will  produce  this 
creaking. 

The  history,  given  by  the  patient  is  almost  invariably  as  fol- 
lows: After  a  period  of  comparative  idleness,  he  went  to  work  at 
moving  furniture  or  polishing  wood  or  some  occupation  requiring 
equally  severe  muscular  effort.  Nexl  day  his  arm  was  sore,  but 
he  kept  on  working  until  the  pain  compelled  him  to  stop.  This 
crepitus  may  persist  for  five  days  or  a  week  after  work  has  been 
given  up,  although  if  the  hand  is  kept  absolutely  at  rest  on  a 
splint,  it  usually  disappears  in  a  day  or  two.  In  slight  cases  it 
may  wear  off  in  a  few  minutes — during  the  diagnostic  manipula- 
tion by  a  class  of  students,  for  example.  In  some  workshops  this 
tenosynovitis  is  of  common  occurrence  among  the  new  men  em- 
ployed. 

While  the  above  mentioned  cases  represent  the  usual  type  of 
tenosynovitis,  the  writer  has  known  this  lesion  to  be  produced 
in  the  sheath  of  the  extensor  tendon  of  the  index-finger,  the  cor- 
responding metacarpal  bone  having  been  fractured  some  weeks  pre- 
viously, and  the  patient  having  returned  to  work  while  there  was 
still  a  sharp  projection  posteriorly  at  the  site  of  fracture,  due 
partly  to  displacement  and  partly  to  callus.  Pulling  the  extensor 
tendon  backward  'and  forward  over  this  bony  prominence  set  up 
the  dry  tenosynovitis. 

Treatment. — The  treatment  of  these  cases  is  comprised  in 
two  words — rest  and  counter-irritation,  the  former  of  which  is 
far  more  important,  while  the  latter  will  relieve  the  acute  pain 
which  exists  in  the  first  few  days. .  A  light  splint,  compound 
iodine  ointment,  and  a  gauze  or  starch  bandage  make  up  the  dress- 
ing which  should  be  left  in  place  for  four  or  five  days.  If  symp- 
toms persist,  the  dressing  should  be  repeated.  The  patient  should 
be  advised  to  begin  very  gradually  to  use  the  hand. 

Serous  Synovitis. — The  joints  of  the  upper  extremity  are 
not  so  prone  to  fill  with  fluid  after  a  traumatism  as  are  the 
joints  of  the  lower  extremity.  Still  such  serous  effusions  occur. 
Figure  157  shows  distention  of  the  right  shoulder- joint  fol- 
lowing an  unrecognized  dislocation.  Six  ounces  of  the  fluid 
which  was  slightly  bloody,  was  aspirated.  Xote  the  flattening  of 
the  outline  of  the  shoulder  which  resulted  from  the  aspiration 
(Fig.  158). 


SEROUS   SYNOVITIS  345 

Fluid  in  the  elbow-joint  distends  the  arm  posteriorly  on  either 
side  of  the  olecranon.  A  small  amount  of  fluid  will  give  fluc- 
tuation. 

Injuries  of  the  joints  of  the  wrist  and  fingers  usually  cause  so 
much  swelling  of  the  overlying  skin  and  subcutaneous  tissue  that 


Fig.  157. — Aspiration  of  Right  Shoulder-joint  for  Traumatic  Synovitis;  Six 
Ounces  of  Bloody  Serum  Removed. 

the  outline  due  to  fluid  in  the  joint  is  obscured.  In  a  chronic 
synovitis  the  fluid  in  the  joint  is  readily  recognized.  It  is  gen- 
erally of  a  tubercular  character  (p.  440). 

The  treatment  of  serous  synovitis  is  that  of  the  injury,  of 
which  the  effusion  is  only  a  symptom.  The  amount  of  fluid  will 
rarely  be  so  great  as  to  require  aspiration. 

Bursitis. — The  olecranon  bursa  may  fill  with  serum  as  the 
result  of  a  single  severe  blow  or  after  repeated  slight  traumatisms 
(miner's  elbow).  It  forms  a  smooth,  tense,  somewhat  tender, 
fluctuating  tumor  between  the  skin  and  the  olecranon  process 
(Fig.  158).  If  the  skin  is  broken  by  the  injury,  the  bursa  is 
likely  to  become  infected,  and  then  redness  and  edema  of  the 
skin  will  be  added,  and  the  tenderness  Avill  be  greatly  in- 
creased.    If  the  bursa  is  punctured  there  will  be  a  discharge  of 


346      INJURIES   TO   THE   SOFT    PARTS   OF   THE   ARM    AND   HAND 

thin  mucous  or  purulent  fluid.  For  infected  bursitis  see 
page  427. 

Other  bursse  of  the  arm  are  rarely  affected  by  an  injury. 

Treatment. — The  treatment  of  an  unromplicated  case  of 
olecranon  bursitis  consists  in  rest  to  the  joint  and  pressure,  -with 
wet  dressings^if  the  skin  is  abraded.  In  a  later  stage  of  the  trou- 
ble, counterirritation,  then  aspiration  and  pressure,  may  be  tried. 


Fig.  158. — Acute  Traumatic  Serous  Olecranon  Bursitis 
Cured  by  aspiration  and  pressure. 


If  these  measures  fail,  the  bursa  may  be  opened  longitudinally, 
and  its  cavity  drained  with  gauze,  so  that  it  will  heal  by  granula- 
tions. A  better  plan  is  to  dissect  out  the  bursa  and  suture  the 
wound.  This  requires  a  general  anesthetic,  and  takes  longer,  but 
it  does  away  with  a  tedious  period  of  recovery.  (Compare  the 
paragraphs  on  diagnosis  and  treatment  of  the  prepatellar  bursa,  p. 
476.) 


CHAPTER    XIV 

DISLOCATIONS    AND    FRACTURES    OF    THE 
ARM    AND    HAND 

DISLOCATIONS 

The  records  of  a  large  hospital  for  a  period  of  years  show 
that  two-thirds  of  the  dislocations  treated  there  involved  the  shoul- 
der-joint, and  that  three-fourths  of  all  dislocations  treated  were  of 
some  joint  of  the  arm  or  hand. 

A  dislocation  of  a  joint  is  an  injury  by  which  one  of  the 
articulating  bones  has  been  pushed  out  of  its  normal  relation 
to  the  other.  The  dislocation  may  be  partial  or  complete.  It 
may  be  reduced  spontaneously  at  the  time  of  injury,  in  which 
case  only  the  symptoms  of  a  sprain  will  persist.  In  other  cases 
reduction  is  easily  accomplished ;  while  in  still  others  it  is  diffi- 
cult, and  may  even  be  impossible  without  an  operation. 

The  symptoms  of  dislocation  are  those  of  a  sprain  of  the  joint, 
viz.,  pain,  swelling,  tenderness,  and  possibly  ecchymosis,  and  in 
addition  marked  deformity,  and  great  limitation  of  motion.  But 
these  last  named  symptoms,  which  are  so  characteristic  in  many 
cases,  may  in  others  be  obscured  by  the  swelling.  Axial  deviation 
of  the  bones  is  another  symptom  which  is  often  of  great  diagnostic 
value. 

General  Remarks  on  Treatment.— There  are  two  gen- 
eral methods  of  reducing  a  dislocated  bone.  One  is  to  make  trac- 
tion until  the  distal  bone  slips  into  its  true  relation  to  the  proximal 
bone.  The  other  plan  is  to  swing  the  lower  end  of  the  distal 
bone  toward  the  side  on  which  it  is  displaced ;  for  example,  flexion 
in  case  of  an  anterior  dislocation  of  the  finger,  overextension  in 
case  of  a  backward  dislocation. 

Reduction  is  interfered  with  by  muscular  contraction,  by  the 
irregular  shape  of  the  bones,  by  intervening  ligaments  or  other 
tissues. 

347 


348     DISLOCATIONS   AND   FRACTURES   OF  THE   ARM   AND   HAND 

.Muscular  contraction  may   be  overcome  by  an  anesthetic  or 

by  long  continiii'il  tract  inn  in  Buch  a  manner  as  to  tire  out  the 
muscles  or  by  dexterity  on  the  part  of  the  surgeon,  so  that  manipu- 
lation is  made  when  the  patient's  attention  is  distracted,  and  his 
muscles  arc  oft'  their  guard.  The  various  motions  made  for  reduc- 
tion should  never  be  violent  nor  powerful.  That  which  one  can 
accomplish  with  greal  force  can  almosl  alwavs  be  accomplished 
with  little  force  if  properly  directed  for  a  sufficient  time;  and 
permanent  injury  is  likely  to  follow  the  use  of  violence. 

Manipulation  of  the  bones  at  the  joint,  while  an  assistant 
makes  traction  at  a  distance,  will  favor  reduction  by  guiding  one 
bone  past  the  other,  and  through  the  rent  in  the  capsule  if  the 
bone  has  protruded.  Such  action  may  well  be  compared  to  draw- 
ing a  shoe-button  through  the  buttonhole  bv  means  of  a  button- 
hook. 

If  all  other  measures  fail  to  reduce  a  dislocation,  an  incision 
should  be  made  for  this  purpose.  The  risk  of  infection  and  a 
subsequent  stiff  joint  is  not  great  when  the  operation  is  properly 
performed.  It  is  better  to  assume  this  risk  than  to  suffer  the 
permanent  disablement  of  an  unreduced  dislocation. 

A  common  mistake  is  to  give  too  favorable  a  prognosis  after 
a  dislocation  has  been  satisfactorily  reduced.  Except  in  cases  in 
which  the  capsule  of  a  joint  is  abnormally  loose,  the  bones  can- 
not be  dislocated  without  producing  at  least  as  much  injury 
to  the  surrounding  parts  as  exists  in  a  severe  sprain.  While 
such  injury  is  many  times  perfectly  recovered  from,  the  con- 
valescence may  be  most  tedious,  and  in  many  cases  the  func- 
tions of  the  joint  are  never  fully  regained.  This  is  especially 
true  if  the  interval  between  dislocation  and  reduction  is  a 
long  one. 

The  question  is  sometimes  asked,  How  long  after  the  occur- 
rence of  a  dislocation  is  it  possible  to  replace  the  bone  ?  ISTo  defi- 
nite answer  can  be  given.  My  own  experience  tends  to  show  that 
manipulation  is  rarely  successful  if  the  interval  is  more  than  four 
weeks.  Furthermore,  if  a  reduction  is  then  accomplished,  it  is 
less  complete  than  when  accomplished  promptly,  and  extra  pre-( 
cautions  are  needed  to  keep  the  bone  in  place.  Before  attempting 
to  replace  the  bone,  the  surgeon  should  move  it  about  in  all  direc- 
tions, to  break  up  adhesions,  overcome  stiffness  of  the  muscles, 


GENERAL   REMARKS    ON   TREATMENT 


349 


ll,1,J 


Fig.   159. — Dislocation  of  the  Thumb  op  Seven  Years'  Duration.     Patient  a 

boy  aged  twelve  years. 

and  so  to  gain  as  much  freedom  of  motion  as  possible.     ISTot  until 
this  has  been  clone  should  the  specific  motions  of  reduction  be  per- 


1 

■ 

wk. 

I 

V 

k 

1 

" 

Pss*        I 

\ 

jgER 

Fig.  160. — Radiograph  to  Show  Relations  of  Bones  in  Dislocation  of  the 
Thumb  of  Seven  Years'  Duration.  Same  subject  as  Fig.  159.  Note  the 
formation  of  a  new  bony  articulation  on  the  back  of  the  metacarpal. 


350      DISLOCATIONS    AM)    FRACTURES   OF   THE    ARM    AM)    HAM) 

formed.    In  these  late  cases  a  general  anesthetic  is  absolutely  indi- 
cated. 

The  condition  of  an  unreduced  dislocation  improves  some- 
what as  months  go  by.  The  ends  of  the  hones  form  imperfect 
sockets  for  themselves,  so  that  the  functions  of  the  joint  are  par- 
tially restored,  but  its  use  is  more  or  less  painful.  The  deformity 
is  of  course  permanent.  These  points  are  strikingly  illustrated  in 
Figures  L59  and  ICO.  The  radiograph  shows  both  the  bony  out- 
lines and  the  contour  of  the  dislocated  thumb.  In  this  case  subse- 
quent growth  of  the  bones  has  increased  their  abnormality. 

By  operation  in  a  case  of  long  standing  dislocation  one  may 
reasonably  hope  to  secure  a  correct  alinement  of  the  hones  and 
some  improvement  of  function  with  less  pain.  A  normal  joint 
may  he  hoped  for,  bill  should  never  he  promised.  The  ultimate 
success  depends  not  a  little  upon  the  faithful  performance  of 
active  and  passive  motions  of  the  joint,  massage,  and  hot  bathing. 

Dislocations  of  the  Shoulder. — The  humerus  may  be  dis- 
located upon  the  scapula  in  any  direction  excepting  upward.  An 
upward  dislocation  can  only  take  place  if  the  acromion  process  is 
broken  off,  and  this  accident  rarely  happens.  The  form  of  dislo- 
cation which  exists  in  more  than  ninety-five  per  cent  of  the  cases 
is  downward  and  forward  beneath  the  coracoid  process.  The  in- 
jury is  usually  produced  by  a  fall  on  the  outstretched  arm  or 
hand.  The  capsule  of  the  joint  is  torn  anteriorly  in  its  lower 
part. 

The  signs  peculiar  to  dislocation  of  the  humerus  are  absence 
of  the  head  of  the  bone  from  its  socket,  flattening  of  the  shoulder, 
projection  of  the  elbow,  and  the  impossibility  of  bringing  it  to 
the  side  of  the  body,  and  most  important  of  all,  the  presence  of 
the  head  of  the  bone  in  an  abnormal  situation,  usually  below  the 
coracoid  process.  There  is  also  a  difference  in  the  length  of  the 
two  arms,  measured  from  the  tip  of  the  acromion  to  the  external 
condyle  of  the  humerus.  There  is  a  shortening  on  the  affected 
side,  Avhich  is  increased  by  abduction  of  the  arm. 

Treatment. — Reduction  of  the  bone  by  a  direct  pull  upon 
the  arm  is  a  difficult  procedure,  often  requiring  great  force,  and 
exposing  the  patient  to  injury  of  the  axillary  vessels  or  nerves; 
but  a  long  continued,  slight  pull  will  often  accomplish  the  end 
in  view  without  great  pain  and  without  serious  risk.      Stimson 


DISLOCATIONS   OF  THE   ELBOW  351 

carries  this  out  by  allowing  tlie  patient  to  lie  upon  a  high  canvas 
cot,  with  his  arm  hanging  through  a  hole  in  the  canvas.  To  his 
wrist  is  attached  a  two  pound  weight.  The  traction  will  grad- 
ually overcome  the  muscles  and  will  bring  the  head  of  the  bone 
back  into  position  in  less  than  ten  minutes. 

The  usual  method  of  reducing  a  dislocated  humerus  is  to 
place  the  patient  upon  his  back  on  a  firm  table;  to  flex,  extend, 
abduct,  and  rotate  the  humerus  for  several  minutes,  in  order  to 
break  up  adhesions,  and  to  partially  tire  out  the  muscles.  The 
next  step  is  to  flex  the  forearm  on  the  arm,  and  to  forcibly  rotate 
the  latter  outward  for  two  or  three  minutes  until  the  muscles  yield 
to  the  steady  tension.  With  the  arm  still  rotated,  the  elbow  is 
carried  upward  across  the  chest,  and  as  the  head  of  the  bone  slips 
into  its  socket,  the  hand  is  brought  over  to  the  opposite  shoulder, 
and  fixed  there  by  a  strap  of  adhesive  plaster  or  a  bandage.  This 
simple  manipulation,  known  as  Kocher's  method,  will  usually  suc- 
ceed in  reducing  a  fresh  dislocation.  It  can  be  performed  either 
with  or  without  an  anesthetic. 

In  other  cases  inward  rotation  of  the  arm,  followed  by  a  sud- 
den hitch  outward  of  the  upper  arm,  will  throw  the  head  of  the 
bone  back  into  place. 

When  the  dislocation  has  been  reduced  the  arm  should  be 
kept  in  a  sling,  but  it  need  not  be  firmly  bandaged  to  the  body 
unless  the  patient  is  very  untrustworthy.  Such  close  confine- 
ment tends  toward  stiffness  of  the  shoulder,  and  this  should  be 
avoided  when  possible.  The  shoulder  should  therefore  be  bathed 
and  massaged  daily,  and  slight  passive  and  active  motions  allowed 
(see  treatment  of  sprain,  p.  339).  The  elbow  should  not  be 
raised  to  the  level  of  the  shoulder  for  two  or  three  weeks,  lest 
the  dislocation  be  reproduced. 

Dislocations  of  the  Elbow. — Dislocation  of  the  elbow  is 
not  a  common  accident,  for  the  reason  that  the  ulna  is  so  closely 
articulated  with  the  humerus  that  an  injury  is  more  likely  to  break 
the  lower  part  of  the  humerus  than  it  is  to  produce  a  dislocation. 

The  head  of  the  radius  may  be  dislocated  either  backward  or 
forward  (Fig.  161)  or  to  one  side. 

The  commonest  form  of  elbow  dislocation  is  the  backward 
dislocation  of  both  radius  and  ulna  (Fig.  162),  with  or  without 
fracture  of  the  coronoid  process.     If  no  fracture  exists,  the  dis- 


352      DISLOCATIONS    AXT)    FRACTURES    OF   THE    ARM    AND    HAND 

location  is  of  necessity  an  extreme  one,  since  the  corouoid  process 
is  carried  behind  the  articular  surface  of  the  humerus.  This 
produces  a  deformity  which  should  not  be  overlooked.     The  tendon 


Fig.  161. — Radiograph  of  Forward  Dislocation  of  the  Head  of  the  Radius, 
Five  Months'  Duration,  and  Fracture  of  the  Ulna  of  Three  Weeks' 
Duration.     Patient  a  girl  aged  seven  years. 


of  the  triceps  is  tightened  "when  an  attempt  is  made  to  flex  the 
forearm ;  and  the  whole  olecranon  portion  of  the  ulna  is  posterior 
to  the  condyles  of  the  humerus  when  the  forearm  is  at  right  angle 
with  the  arm.  Normal  motions  of  the  joint  are  considerably 
limited.  The  head  of  the  radius,  recognized  by  palpation  and 
rotation  of  the  wrist,  may  be  felt  to  the  outer  side  of  the  olecranon. 
In  case  the  ulna  alone  is  dislocated,  the  head  of  the  radius  will 
remain  in  its  natural  position.  The  dislocation  of  the  forearm 
in  this  case  will  not  be  directly  backward,  but  the  forearm  will 
swing  round  upon  the  head  of  the  radius  as  a  pivot,  so  that  if 
the  forearm  is  held  at  right  angles  with  the  arm  in  the  position 
of  supination,  the  hand  will  be  considerably  nearer  the  median 
line  of  the  body  than  it  ought  to  be.  If  the  radius  is  dislocated 
with  the  ulna  the  forearm  may  be  carried  directly  backward,  or 
it  may  be  more  or  less  laterally  displaced.  In  every  case  of  dis- 
location or  other  injury  about  the  elbow,  it  is  of  the  greatest  im- 
portance to  determine  the  relations  of  the  two  condyles  of  th© 
humerus,  the  tip  of  the  olecranon  and  the  head  of  the  radius. 


DISLOCATIONS   OF   THR   ELBOW 


.353 


Dislocation  at  the  elbow  is  often  combined  with  fracture  of 
some  bone.  In  this  case  the  characteristic  signs  will  be  more  or 
less  obscured.  Indeed,  injuries  of  the  elbow-joint  afford  some 
of  the  most  difficult  diagnoses,  and  the  surgeon  should  not  miss 
the  aid  offered  by  radiographs  made  in  the  anteroposterior  and 
bilateral  directions. 

Treatment. — Backward  dislocation  of  the  elbow- joint,  if  of 
recent  occurrence,  can  usually  be  reduced  without  difficulty.  The 
patient  should  be  fully  anesthetized.  The  range  of  motion  of  the 
forearm  on  the  arm  is  then  to  be  increased  by  repeated  gentle 
manipulation  in  all  directions,  and  then,  while  an  assistant  fixes 
the  upper  arm,  the  surgeon  makes  an  attempt  to  unlock  the  ulna 
from  the  humerus  and  bring  it  forward.  Sometimes  this  is  easily 
accomplished ;  sometimes  a  number  of  efforts  must  be  made  before 
success  is  obtained.     As  in  all  dislocations,  strategy  rather  than 


Fig.  162. — Radiograph  Showing  Backward  Dislocation  of  Both  Radius  and 
Ulna  of  Five  Months'  Duration.  Patient  a  man  aged  fifty-eight.  An  opera- 
tion was  necessary  to  reduce  this  dislocation. 


great  force  should  be  employed.  It  is  sometimes  possible  to  slide 
the  ulna  toward  the  inner  side  of  the  humerus,  and  then  to  bring 
it  forward.  When  one  bone  has  been  reduced,  or  in  case  only  one 
of  the  bones  is  dislocated,  the  bone  which  is  in  place  acts  as  a 
lever  to  drag  the  other  one  into  place  if  a  firm  lateral  motion, 
either  abduction  or  adduction,  is  combined  with  the  forward  trac- 
tion upon  the  forearm. 


::.->■  i    dislocations  and  fractures  of  the  arm  and  hand 

It  is  said   thai    reduction   by   manipulation   is  rarely  possible 

in  di>lor;it  ion  of  llic  rlliow-joint  which  lnis  lasted  a  month  or  more. 
In  every  case  the  manipulation  should  &rs1  be  tried,  and  tried 
most  thoroughly,  not  only  on  accounl  of  the  possibility  thai  it  may 
succeed,  but  because  the  added  freedom  of  motion  thereby  obtained 

is  of  the  greatest  help  to  the  operator  in  case  he  has  to  expose  the 
hours  through  incisions.  The  besl  incisions  to  employ  in  this  in- 
stance are  two  lateral  ones,  linear  longitudinally  when  the  fore- 
arm is  extended,  bu1  more  or  less  curved  iu  the  semiflexed  position 
of  an  old  dislocation. 

When  the  elbow  has  been  reduced  by  manipulation  or  opera- 
tion, the  forearm  should  be  flexed  to  a  right  angle  and  kept  so 
by  a  sling,  or  a  gypsum  bandage,  or  molded  splints.  As  soon  as 
possible  passive  motions  and  massage  and  hot  bathing  should  be 
instituted.  Such  treatment  should  be  begun  within  a  week  if  a 
fresh  dislocation  has  been  reduced  by  manipulation,  and  as  soon 
as  the  wounds  will  permit  in  cases  reduced  by  an  open  operation. 
It  is  well  to  remember  that  oft-repeated  slight  motions  have  a 
far  greater  curative  value  than  a  few  violent  ones.  For  this  rea- 
son active  motions  made  by  the  patient  himself  are  especially  to 
be  encouraged.  He  should  be  given  certain  definite  motions  to 
practise  several  times  daily  which  will  tend  to  increase  the  exist- 
ing range  of  motion. 

Subluxation  of  the  Radius. — Dislocation  downward  of  the 
head  of  the  radius,  or  subluxation,  as  it  has  been  called,  may  be 
produced  in  young  children  by  jerking  them  or  lifting  them  sud- 
denly by  one  hand.  The  head  of  the  radius  is  pulled  downward 
out  of  the  coronoid  ligament,  usually  without  other  injury.  Ex- 
amination will  show  a  certain  amount  of  tenderness  at  the  seat  of 
injury  and  loss  of  function,  especially  in  the  matter  of  pronation 
and  supination  of  the  hand ;  but  these  signs  are  frequently  ob- 
scured by  the  fact  that  a  young  child  will  refuse  to  make  any 
motions  of  an  injured  joint  through  fear.  Hence  the  symptoms 
elicited  may  differ  in  nowise  from  those  of  a  sprain  of  the  elbow. 
The  only  characteristic  sign,  therefore,  is  the  absence  of  the  head 
of  the  radius  from  its  normal  position,  and  its  presence  slightly 
below  this  point.  Careful  measurement  from  the  external  condyle 
of  the  humerus  to  the  styloid  process  of  the  radius  will  show  that 
the  distance  is  slightly  increased  upon  the  injured  side.     A  differ- 


DISLOCATION    OF   THE   THUMB  355 

ential  diagnosis  between1  this  injury  and  fracture  of  the  neck  of 
the  radius  can  best  bo  made  by  an  X-ray  examination. 

Treatment. — This  dislocation  is  easily  reduced,  either  with 
or  without  an  anesthetic.  The  upper  arm  should  be  grasped  firmly 
near  its  lower  end  at  the  same  time  that  the  hand  and  lower  end 
of  the  radius  is  also  firmly  held.  The  forearm  should  be  extended, 
and  the  radius  pushed  steadily  upward  at  the  same  time  that  it  is 
rotated  slightly  to  right  and  left.  In  this  manner  it  can  be  slipped 
back  into  place  much  as  a  peg  is  worked  into  a  hole. 

Dislocation  of  the  Wrist. — Dislocation  of  the  wrist  is  a 
rare  occurrence,  owing  to  the  fact  that  the  lower  end  of  the  radius 
is  broken  by  an  injury  which  might  otherwise  cause  a  dislocation. 
The  deformity,  whether  anterior  or  posterior,  is  extreme,  resem- 
bling that  of  Colles's  fracture  with  marked  displacement  of  the 
lower  fragment.  Motion  at  the  wrist- joint  is  greatly  limited.  The 
normal  relation  of  the  tips  of  radius  and  ulna  is  preserved,  and 
measurements  of  these  two  bones  will  show  them  to  be  of  normal 
length.  After  reduction  of  the  dislocation  the  hand  should  be  kept 
for  two  weeks  or  more  upon  an  anterior  splint. 

Dislocation  of  the  Thumb. — Dislocation  of  the  carpo- 
metacarpal joint  of  the  thumb  occurs  rarely.  Fracture  of  the 
metacarpal  bone  is  common.  If  the  fracture  is  near  the  base  it 
may  be  difficult  to  differentiate  it  from  a  dislocation  without  the 
use  of  the  X-ray.  Crepitus,  a  difference  in  measurements,  and 
the  impossibility  in  making  a  perfect  reduction  will  indicate  frac- 
ture; but  in  the  presence  of  considerable  swelling  these  signs  may 
not  be  clearly  obtained. 

This  dislocation  is  easily  overcome  by  manipulation.  Adhesive 
plaster  strapping  will  prevent  its  recurrence  (see  Fig.  155,  p.  340), 
or  a  starch  bandage  may  be  applied  to  the  thumb  and  wrist. 

The  proximal  phalanx  of  the  thumb  may  be  dislocated  back- 
ward. The  anterior  portion  of  the  capsule  is  torn  from  the  meta- 
carpal and  the  thumb  rests  upon  the  posterior  surface  of  the  meta- 
carpal, sometimes  forming  an  angle  of  ninety  degrees  with  its 
shaft.  It  is  evident  that  such  a  dislocation,  if  unreduced,  will 
render  the  thumb  nearly  useless  (Figs.  159  and  160,  p.  349). 
This  condition  is  easily  recognized.  A  fracture  may  be  followed 
by  posterior  displacement  of  the  distal  portion,  but  it  does  not  give 

such  an  axial  deviation  as  dislocation. 
25 


356     DISLOCATIONS   AND   FRACTURES  OF  THE   ARM  AND  HANI) 

Treatment. — Reduction  is  soniet hues   made  difficult  by   the 
interposition  of  the  torn  capsule  or  the  outer  sesamoid  bone,  or  by 

the  position  of  the  head  of  the  uu'kicarpa]  between  the  two  heads 


Fig.  163. — Full  Extension  op  Adult  Thumbs.     Right  thumb  normal;  left  thumb 
abnormally  overextended. 

of  the  flexor  brevis  muscle.  To  avoid  these  hindrances  the  sur- 
geon should  first  bring  the  metacarpal  into  the  center  of  the  palm 
so  as  to  relax  the  flexor  brevis  muscle,  should  flex  the  distal  pha- 
lanx to  relax  the  flexor  longus  tendon,  and  should  increase  the 
dorsal  flexion  of  the  proximal  phalanx  and  rotate  the  bone  slightly 
from  side  to  side  in  order  to  dislodge  any  structures  which  have 
intervened  between  the  bones.  The  base  of  the  phalanx  is  next  to 
be  pushed  along  the  posterior  surface  of  the  metacarpal  until  it 
is  partly  beyond  it.  Not  until  then  should  flexion  be  attempted. 
If  reduction  is  not  accomplished,  the  patient  should  be  anes- 
thetized, and  another  attempt  at  reduction  should  be  made.  If 
this  is  not  completely  successful,  the  joint  should  be  exposed  by  a 


DISLOCATION    OF   A   FINGER 


357 


radial  incision  and  normal  relations  established.  Perfect  restora- 
tion of  function  should  follow.  This  operation  should  also  be 
performed  in  cases  of  dislocation  of  long  standing.  Under  such 
circumstances  resection  of  the  head  of  the  metacarpal  will  usually 
be  necessary.  The  results  are  then  not  as  perfect,  but  the  use  of 
the  thumb  is  far  greater  than  if  it  is  allowed  to  remain  perma- 
nently displaced. 

In  either  operation  the  wound  may  be  closed  at  once  or  a  horse- 
hair drain  may  be  used.  This  should  extend  only  as  far  as  the 
capsule  of  the  joint  and  should  be  removed  in  forty -eight  hours  if 
there  is  no  suppuration  of  the  wound.  The  thumb  should  be  band- 
aged in  a  slightly  flexed  position.  If  the  joint  suppurates  it  should 
be  treated  by  drainage  through  the  incision,  and  a  wet  dressing 
and  a  splint  should  be  applied,  as  described  on  page  425. 

Overextension  of  Thumb. — Overextension  of  the  first  phalanx 
of  the  thumb,  simulating  a  dislocation,  is  possible  in  many  per- 
sons. It  is  due  to  an  abnormal  laxity  of  the  anterior  ligaments, 
either  the  persistence  of  an  infantile  condition  or  the  result  of 
traumatism  in  childhood  (Fig.  163). 

Dislocation  of  a  Finger. —Dislocation  of  the  metacarpo- 
phalangeal joint  of  a  finger  may  occur,  but  this  is  not  common,  on 
account  of  the  strong  ligaments ;  consequently  fracture  of  the  head 
of  the  metacarpal  is  the  usual  result  of  injury  in  this  locality.  A 
differential  diagno- 
sis between  the  two 
can  usually  be  made 
by  taking  exact 
measurements  and 
comparing  them 
with  those  of  the 
opposite  hand.  A 
pair  of  calipers  is 
convenient  for  this 
purpose.  A  differ- 
ence may  also  be 
observed  in  the 
knuckle    when    the 

finoers     are     flexed         FlG-   164- — P°STKRIOR  Dislocation  of  the  Terminal 

to  .  '  Phalanx  of  the  Forefinger,  and  Radiograph  of 

In  this  position  the  the  Same.    Patient  a  man  aged  twenty-three  years. 


358      DISLOCATIONS   AND    FRACTURES   OF   THE   ARM    AND    HAND 

knuckle  is  wholly  formed  1  •  \  the  head  of  the  metacarpal,  and  will 
not,  therefore,  be  altered  in  a  dislocation,  whereas  in  fracture  it 
will  be  less  prominent. 

Dislocation  of  one  phalanx  of  the  finger  upon  another  may  be 
anteroposterior  (Fig.  164)  or  lateral  (Figs.   L66  and  167).     The 


Fig.  165. — Reduction  of  Posterior  Dislocation  of  the  Terminal  Phalanx  of 
the  Forefinger  by  Operation.  Photograph  two  weeks  later.  Same  patient 
as  shown  in  Fig.  164. 

cause  is  usually  a  blow  upon  the  finger-tip  or  a  fall  upon  the  out- 
stretched hand.  Sometimes  the  finger  is  caught  between  two  mov- 
ing hard  surfaces,  which,  in  the  lateral  dislocation  here  illustrated, 
were  the  teeth  of  a  horse. 

The  diagnosis  of  these  dislocations  is  readily  made  unless  there 
is  great  swelling.  The  eye  can  detect  the  error  in  the  bony  aline- 
ment,  which  cannot  be  corrected,  while  the  range  of  motion  of  the 
joint  will  be  distinctly  limited. 


DISLOCATION    OF   A    FINOEK 


359 


If  the  dislocated  bone  is  allowed  to  remain  in  its  abnormal 
position  the  finger  will  not  be  entirely  useless,  but  the  range  of 
motion  of  the  affected  joint  will  never  be  fully  regained  and  the 
deformity  will  be  permanent.  Hence,  treatment  is  indicated  in 
most  cases,  even  of  an  operative  character,  if  reduction  cannot 
otherwise  be  obtained. 

Treatment. — Reduction  of  a  partial  dislocation  is  simple,  and 
is  usually  accomplished  by  a  bystander  or  by  the  patient  himself. 
In  some  cases,  however,  torn  ligaments  intervene  between  the  ends 
of  the  bones,  making  perfect  reduction  impossible.  The  reduction 
of  a  complete  dislocation  is 
more  apt  to  be  interfered 


Fig.  166. — Lateral  Dislocation 
of  Little  Finger  due  to  the 
Bite  of  a  Horse. 


Fig.  167. — Radiograph  of  Lateral  Dislo- 
cation of  Little  Finger.  Same  patient 
as  shown  in  Fig.  166. 


with  by  the  interposition  of  the  ligaments,  and-  the  various  pulls 
and  twists  of  sympathetic  friends  will  in  such  cases  merely  in- 
crease the  traumatism  and  its  resulting  swelling. 


360     DISLOCATIONS   AND   FRACTURES   OF   THE   ARM   AND   HAND 

As  in  all  dislocations;,  the  simplest  measures  should  tirst  be 
tried.  Extension  should  first  be  made  upon  the  distal  portion  at 
the  same  time  that  the  dislocated  bone  is  manipulated.  If  this 
fails,  the  axial  deviation  of  the  displaced  distal  bone  should  be 
exaggerated,  and  while  traction  is  made  upon  it  in  this  direction 
an  attempt  should  be  made  to  crowd  its  base  past  the  head  of  the 
proximal  bone.  Unless  this  last  effort  is  successful  it  is  useless 
to  swing  the  shaft  of  the  bone  into  a  correct  line.  If  these  efforts 
fail,  continuous  traction  may  be  employed.  A  pound  or  two  pound 
weight  should  be  fastened  to  the  finger  by  adhesive  strips,  and  the 
hand  allowed  to  hang  vertically  downward.  If  this  method  is  not 
successful  in  fifteen  or  twenty  minutes,  it  should  be  abandoned. 

If  all  these  methods  fail,  it  is  necessary  to  expose  the  joint 
by  two  lateral  incisions,  to  remove  intervening  ligaments  and  new 
formed  cicatricial  tissue  if  the  dislocation  is  an  old  one,  and  to 
pry  the  bones  back  into  place.  When  this  has  been  accomplished 
the  wounds  should  be  closed  by  suture  with  horsehair  or  fine 
black  silk  (Fig.  165). 

Whatever  the  treatment,  when  the  dislocation  has  been  reduced 
it  is  not  likely  to  return.  It  is  only  necessary  to  apply  an  anterior 
splint  of  wood  to  the  finger,  or  its  motions  may  simply  be  confined 
by  strips  of  adhesive  plaster  wound  about  the  finger  spirally  or 
circularly. 

In  any  case  in  which  a  bone  is  used  as  a  lever  in  manipula- 
tions the  risk  of  fracture  should  be  borne  in  mind. 

If  a  dislocation  remains  unreduced  for  some  weeks,  fibrous  tis- 
sue forms  about  the  ends  of  the  bones,  so  that  reduction  will  be 
impossible  without  operation.  The  X-ray  may  show  no  trace  of 
this  tissue,  but  may  give  the  impression  that  reduction  will  be 
very  easy,  as  was  the  case  in  the  patient  whose  finger  is  shown  in 
Figures  166  and  167. 

If  the  patient  is  a  child,  and  the  dislocation  remains  unre- 
duced, continued  growth  will  alter  the  shape  of  the  bones,  and 
may  even  establish  a  new  joint,  as  shown  in  Figure  160, 
page  349. 

Drop-finger. — A  blow  upon  the  end  of  the  finger  may  rup- 
ture the  posterior  part  of  the  capsule  of  the  distal  joint.  As  this 
part  of  the  capsule  is  the  extensor  tendon  of  the  finger  spread  out 
flat,  it  is  impossible  in  such  circumstances  to  extend  the  distal  pha- 


DROP-FINGER  361 

lanx,  which  drops  forward  (Figs.  168  and  169).     This  deform- 
ity is  known  as  drop-finger  or  mallet-finger  or  "  base-ball-finger." 
Treatment. — If  seen  at  once  and  kept  continuously  in  exten- 
sion for  two  or  three  weeks  by  a  light  anterior  splint,  union  of  the 


Fig.  168. — Drop-Finger  or  Mallet-Finger.  On  account  of  rupture  of  the  extensor 
tendon  which  forms  the  posterior  ligament  of  the  terminal  joint,  extension  is 
impossible. 

tendon  to  the  bone  will  often  take  place.  If  the  deformity  is 
neglected  for  some  days  the  same  treatment  may  be  tried,  but 
with  less  probability  of  success.  If  no  union  results  after  several 
weeks  of  treatment,  an  attempt  should  be  made  to  sew  the  end 
of  the  tendon  to  the  base  of  the  last  phalanx  with  fine  silk.  The 
incision  should  be  a  U-shaped  one,  the  opening  of  the  U  directed 
upward,  the  base  of  the  U  crossing  the  finger  about  midway  be- 
tween the  joint  and  the  point  where  the  skin  is  reflected  to  the 


Fig.  169. — Traumatic  Drop-Finger  of  Three  Months'  Duration.     Patient  aged 

sixty  years. 

nail.  In  turning  this  flap  upward  care  should  be  taken  not  to 
disturb  the  bed  of  the  nail.  In  such  an  operation  the  finest  in- 
struments are  essential  to  success.  In  other  cases  the  posterior 
part  of  the  base  of  the  phalanx  is  pulled  off  with  the  insertion 


362      DISLOCATION*     \\|>    FKAtTl'HES    OF   THE    ARM    AM)    HAND 


of  the  tendon  (  Figs.  L70  and  171).  The  "drop"  of  the  tip  of 
the  ringer  is  I  hen  less  marked,  bill  even  when  the  ringer  is  forcibly 
cxieiided  there  will  still  be  some  deformity.  Treatment  by  an- 
terior   splint    will    give    a    somewhat    thickened    linger    with    good 


Fig.  170. — Radiograph  of  Traumatic  Drop- 
Finger,  Antero-posterior  View.  A  portion 
of  the  terminal  phalanx  has  been  torn  off 
with  the  posterior  ligament. 


Fig.  171. — Radiograph  of  Trau- 
matic Drop  -  Finger,  Lat- 
eral View.  Same  patient  as 
Fig.  170. 


function.  In  order  to  avoid  deformity  the  loosened  fragment 
of  phalanx  should  be  removed  through  a  transverse  incision.  The 
periosteum  should  be  saved  if  possible.  This  or  the  termination 
of  the  tendon  should  be  stitched  to  the  periosteum  of  the  third 
phalanx  or  kept  in  place  by  pressure.  An  anterior  splint  should 
be  worn  for  two  weeks,  and  the  patient  should  avoid  complete 
flexion  of  the  distal  phalanx  for  some  weeks  more. 

In  some  cases  the  terminal  phalanx  of  the  finger  is  overex- 
tended and  bent  directly  backward.  The  term  "  baseball-finger  " 
is  applied  by  some  writers  to  this  condition  exclusively.  It  is  the 
result  of  force  suddenly  applied  to  the  tip  of  the  finger  and  in  most 
instances  the  permanent  deformity  is  due  to  fracture  of  the  ter- 
minal phalanx,  and  not  simply  to  rupture  of  the  anterior  ligament. 


FRACTURES  IN   GENERAL  363 

FRACTURES 

Fractures  in  General. — Diagnosis. — The  diagnostic  points 
of  a  fracture  are  well  known  to  be: 

1.  Pain  and  tenderness; 

2.  Swelling ; 

3.  Ecchymosis ; 

4.  Deformity; 

5.  Shortening ; 

'     6.  Results  of  examination  with  the  X-ray ; 
1.  False  point  of  motion ; 

8.  Crepitus; 

9.  Altered  percussion  note; 

10.  Loss  of  function; 

11.  Results  of  examination  under  general  anesthesia. 
It  is  not  to  be  expected  that  all  signs  of  fracture  will  be  pres- 
ent in  any  given  case.  Most  of  the  signs  may  also  be  due  to  an 
injury  to  the  soft  parts,  or  possibly  to  a  bruise  of  the  bone  itself ; 
but  they  have  a  relative  value,  and  if  certain  of  them  exist  to- 
gether, and  the  history  of  the  injury  is  such  as  to  presuppose  a 
fracture,  a  sufficiently  positive  diagnosis  can  often  be  made,  even 
though  the  pathognomonic  signs  of  false  motion  and  crepitus  are 
not  obtained  and  an  X-ray  examination  is  out  of  the  question. 

Some  further  explanation  of  the  relative  value  of  these  signs 
is  desirable. 

1.  Pain  is  one  of  the  least  valuable  signs,  because  it  varies  so 
in  different  cases.  Its  absence  is  no  proof  that  a  fracture  does 
not  exist.  Tenderness,  that  is,  pain  produced  by  pressure  or 
manipulation,  is  a  far  more  valuable  sign.  In  almost  all  fresh 
fractures  pain  is  caused  by  pressure  directly  upon  the  line  of 
fracture.  If  it  is  produced  at  the  point  of  fracture  by  pressure 
made  upon  the  injured  bone  at  some  other  point,  the  sign  has  a 
greater  significance.  Take,  for  example,  the  case  of  the  ulna,  a 
bone  which  is  often  bruised.  Pressure  on  the  bruised  spot  natu- 
rally causes  pain,  whereas  pressure  on  the  ends  of  the  bone,  made 
by  crowding  together  the  olecranon  and  hand,  will  cause  no  pain. 
In  a  case  of  fracture  such  pressure  will  probably  cause  pain  if 
the  solution  of  continuity  is  complete.  The  same  difference  exists 
when  attempts  are  made  to  bend  a  bone  at  the  suspected  point  of 


364     DISLOCATIONS   AND   FRACTURES   OF  THE   ARM  AND   HAND 

fracture.     In  making  these  tests  one  must  be  careful  not  to  make 
direct  pressure  upon  the  contused  area. 

2.  Swelling  of  the  soft  pari.-  is  such  a  common  sign  after  all 
injuries  that  its  diagnostic  value  is  not  of  ureal  importance.  If 
the  swelling  is  out  of  proportion  to  the  apparent  damage  to  the 
soft  parts,  or  if  it  persists  longer  than  such  apparent  damage 
would  warrant,  it  has  some  value  in  establishing  diagnosis  of  frac- 
fcure.  If  a  deep  swelling  persists  after  the  edema  of  the  skin  has 
disappeared,  its  diagnostic  value  is  greater,  as  it  is  then  probably 
due  to  displaced  bone  or  to  callus. 

3.  Ecchymosis  has  also  a  relative  value  in  establishing  the 
diagnosis  of  fracture.  If  it  occurs  within  a  few  hours  its  diag- 
nostic value  is  slight.  If  the  area  of  ecchymosis  extends  for  three 
or  four  days,  the  value  of  the  sign  as  indicating  fracture  is  far 
greater.  This  fact  indicates  positively  that  some  deep  blood-ves- 
sels have  been  ruptured,  and  in  case  of  suspected  fracture  such 
blood-vessels  are  usually  in  the  bone  itself.  It  is  unusual  to  have 
a  fracture  without  ecchymosis. 

4.  Deformity,  if  one  can  be  certain  that  it  is  true  bony  de- 
formity, is  a  positive  sign  of  fracture  or  dislocation.  The  value 
of  this  sign  rests,  therefore,  on  the  completeness  of  the  examina- 
tion. If  the  patient  is  seen  immediately  after  the  accident,  before 
the  soft  parts  have  had  time  to  swell,  even  a  slight  bony  deformity 
is  readily  made  out.  On  the  following  day  the  deformity  may  be 
massed  by  the  edema  of  the  soft  parts.  In  a  week  or  more,  after 
the  swelling  of  the  soft  parts  has  more  or  less  subsided,  the  bony 
deformity  will  again  be  more  apparent,  but  from  this  time  for- 
ward it  will  be  more  or  less  obscured  by  the  callus. 

Deformity  due  to  fracture  may  be  either  angular  or  due  to 
overlapping  of  the  broken  ends.  Angular  deformity  is  usually 
easier  to  make  out,  especially  if  the  fracture  is  in  a  shaft  of  a  long 
bone.  As  such  fractures  are  rarely  impacted,  the  angle  can  gen- 
erally be  increased  or  diminished  by  manipulation  (sign  ]STo.  7). 

The  deformity  due  to  overlapping,  or  to  driving  one  fractured 
end  into  the  other,  is  easily  made  out,  provided  there  is  no  swell- 
ing of  the  soft  parts  and  the  bone  lies  near  the  surface.  If  the 
fracture  of  the  shaft  of  the  bone  is  transverse,  or  nearly  so,  over- 
lapping of  the  fractured  ends  will  produce  a  marked  deformity, 
and  one  that  is  easily  recognized  in  spite  of  swelling.     This  often 


FRACTURES   IN   GENERAL  365 

happens  in  fractures  of  the  shaft  of  one  of  the  phfibmgcs  mid  of 
the  humerus.  Most  fractures  are,  however,  oblique.  This  is  par- 
ticularly true  of  fractures  near  the  joints,  and  it  is  in  just  the-*' 
cases  that  swelling  is  great  and  diagnosis  is  more  difficult.  Deter- 
mination of  the  long  axis  of  the  portion  of  the  hone  which  can  he 
felt,  and  its  projection,  in  the  mind,  beyond  the  site  of  fracture, 
will  help  the  examiner  to  decide  whether  deformity  exists. 

Marked  deformity  is,  of  course,  produced  by  dislocation,  but 
a  dislocation  can  in  most  cases  be  differentiated  with  certainty 
from  a  fracture  by  the  other  symptoms  which  exist,  and  which  are 
given  in  the  description  of  the  special  fractures  and  dislocations. 

5.  Shortening  is  also  a  positive  sign  of  fracture,  if  one  is  sure 
of  his  measurements.  Many  bones  have  such  definite  prominences 
that  accurate  measurements  can  be  made  and  compared  with  those 
of  the  uninjured  side.  In  other  cases  it  is  better  to  extend  the 
measurements  beyond  the  particular  bone  in  question  until  well 
marked  prominences  are  reached.  Thus,  in  cases  of  suspected 
fracture  of  the  femur,  it  is  customary  to  measure  from  the  ante- 
rior superior  spine  of  the  ileum  to  the  internal  maleolus. 

In  some  cases  a  previous  injury  or  deformity  of  the  affected  or 
non-affected  side  will  render  comparative  measurements  worthless. 

If  a  false  point  of  motion  exists,  measurements  of  the  bone 
may  show  a  difference  when  traction  is  made  upon  the  limb  so  as  to 
overcome  any  shortening  which  exists,  and  when  the  ends  of  the 
bone  are  crowded  together  so  as  to  increase  the  shortening.  This 
difference  in  many  cases  amounts  to  an  inch  or  more.  Measure- 
ments are  of  value  not  only  as  proving  the  existence  of  fracture, 
but  also  to  show  that  reduction  has  been  effected.  In  all  cases 
comparative  measurements  should  be  made  upon  the  sound  side. 

6.  Examination  with  the  X-ray  has  added  more  to  our  knowl- 
edge of  fractures  than  all  other  methods  combined.  The  technic 
of  such  examinations  is  fully  explained  in  special  books  upon  the 
subject,  at  least  one  of  which  should  be  in  the  hands  of  any  one 
who  takes  up  this  method  of  examination.  There  are  three  gen- 
eral points  which  may  well  be  borne  in  mind  by  every  one  who 
sends  a  patient  to  have  an  X-ray  examination  made.  The  first 
point  is  that  a  negative  examination  with  the  nuoroscope  should, 
if  possible,  be  confirmed  by  a  radiograph,  since  fractures  with 
slight  displacement  may  not  be  apparent  to  the  eye.     The  second 


366      DISLOCATIONS    AM)    FRACTURES   OF  THE   ARM    AND    ELAND 

point  is  the  necessity  of  making  radiographs  in  both  the  antero 

posterior  and  lateral  planes,  in  order  to  show  how  much  deformity 
exists  in  both  directions.  The  third  point  is  this,  that  many  cases 
of  supposed  sprain  will  be  shown  in  a  good  radiograph  to  be  cases 
of  fracture. 

7.  A  false  point  of  motion  is  positive  proof  of  fracture.  Its 
absence  does  not  prove  the  absence  of  fracture,  since  the  fracture 
may  be  incomplete  (green  stick  fracture),  <>r  it  may  be  impacted, 
or  it  may  be  so  situated  thai  one  cannot  grasp  both  portions  of 
the  fractured  bone  in  such  a  manner  as  to  demonstrate  their  lack 
of  continuity.  This  is  the  case  in  many  fractures  about  a  joint. 
Sometimes  the  false  point  of  motion  can  be  demonstrated  by  the 
abnormal  motion  which  one  of  the  bones  making-  up  the  joint  has 
upon  the  other,  even  though  the  shorter  fragment  is  quite  inacces- 
sible. This  is  seen  after  fracture  of  the  so-called  anatomical  neck 
of  the  humerus  and  fracture  of  the  neck  of  the  femur. 

In  testing  for  a  false  point  of  motion  the  bones  should  be 
grasped  firmly  above  and  below  the  suspected  plane  of  fracture. 
Gentle  manipulation  should  then  be  made,  calculated  (a)  to  bend 
the  affected  bone  in  an  anteroposterior  direction,  (b)  to  bend  it 
laterally,  (c)  to  slide  one  broken  end  on  the  other  in  an  antero- 
posterior direction,  (d)  to  slide  it  laterally,  (c)  to  rotate  one  end 
upon  the  other,  and  (/')  to  increase  and  diminish  any  existing 
overlapping  by  alternately  pushing  up  anel  then  making  traction 
upon  the  bone  in  the  direction  of  its  long  axis.  These  general 
tests  may  be  varied  to  meet  the  requirements  in  any  particular 
case.  They  are  especially  applicable  to  fractures  in  the  shaft 
of  a  long  bone.  Emphasis  is  laid  on  the  firm  grasp  combined 
with  gentle  manipulation,  for  in  this  way  the  best  results  are 
obtained. 

Sometimes,  if  a  small  portion  of  the  bone  has  been  broken  off, 
its  mobility  may  be  demonstrated  by  making  pressure  first  on  one 
end  or  side  of  the  fragment  and  then  upon  the  opposite  one.  In 
this  manner  it  may  be  tilted  back  and  forth. 

If  the  fracture  is  near  a  joint  the  best  result  is  sometimes 
obtained  by  grasping  with  one  hand  the  main  portion  of  the  frac- 
tured bone,  and  with  the  other  hand  the  bone  or  bones  with  which 
it  articulates,  thus  allowing  the  small  fractured  portion  to  move 
with  the  bones  beyond  the  joint.     A  good  example  of  this  is  found 


FRACTURES   IN   GENERAL  367 

in  fracture  of  one  malleolus,  especially  when  combined  with  Lacera- 
tion of  the  ligaments  of  the  opposite  side. 

8.  Crepitus  or  grating  between  the  broken  surfaces  of  a  bone 
is,  of  course,  a  positive  proof  of  fracture  when  found.  It  should 
be  tested  for  with  gentleness,  according  to  the  directions  given  in 
the  preceding  paragraphs,  under  the  heading  "  False  Point  of 
Motion."  Failure  to  obtain  crepitus  when  a  fracture  exists  may- 
be clue  to  impaction  of  the  fragments,  or  to  lack  of  mobility,  or 
to  the  interposition  of  soft  tissues  or  clotted  blood,  which  allow 
the  bones  to  move  on  each  other  without  grating. 

A  soft  or  false  crepitus  is  often  produced  in  a  joint  by  an 
unnatural  slipping  of  one  bone  upon  the  other.  Tims,  the  shoul- 
der-joint in  many  persons  habitually  gives  out  a  crepitus  when 
manipulated,  and  any  joint  may  do  so  following  an  injury.  This 
source  of  possible  error  can  usually  be  eliminated  by  a  comparison 
with  the  corresponding  joint  of  the  other  side. 

A  blood  clot  in  the  vicinity  of  a  suspected  fracture  will  some- 
times give  a  soft  crepitus  when  pressed  upon.  There  is  also  a 
possibility  of  fibrinous  crepitus  produced  by  the  slipping  of  a  ten- 
don through  an  acutely  inflamed  tendon  sheath  (see  p.  343). 

9.  An  altered  percussion  note  was  at  one  time  heralded  as  a 
sure  sign  of  fracture.  A  stethoscope  is  placed  over  one  end  of 
the  bone  while  the  other  end  is  tapped.  If  the  bone  is  intact  the 
sound  is  transmitted  clearly ;  if  the  bone  is  broken  the  sound  is 
muffled.  The  difference  is  noted  by  comparing  the  results  ob- 
tained on  the  two  sides  of  the  body.  This  test  has  a  limited  appli- 
cation. It  is  obvious  that  there  must  be  no  swelling  of  the  soft 
parts  over  the  points  where  the  stethoscope  is  placed  and  where 
the  bone  is  tapped,  as  otherwise  a  different  sound  will  be  pro- 
duced. Practise  has  shown  that  the  sound  is  frequently  undi- 
minished, even  though  a  fracture  exists,  presumably  because  the 
fractured  ends  of  the  bone  are  in  intimate  contact  with  each  other. 
If  the  ends  are  separated  there  is  a  distinct  difference  in  the  tone. 
For  this  reason  some  observers  claim  that  this  percussion-auscul- 
tation is  a  reliable  sign  of  the  existence  of  soft  tissues  between 
the  fractured  ends  of  a  bone,  and  that  if  the  ends  cannot  be  so 
approximated  that  a  clear  tone  will  be  produced  non-union  may 
be  expected.  Further  testimony  is  needed  upon  this  subject  before 
accepting  this  statement  as  final. 


368     DISLOCATIONS    AND   FRACTURES   OF  THE   ARM   AND  HAND 

in.  Loss  of  function  is  a  valuable  sign  of  fracture,  though  not 
an  absolute  one.     The  function  of  a  bone  is  to  remain  rigid  while 

allowing  million  in  its  associated  joints.  In  a  sense,  most  of  the 
symptoms  mentioned  above  indicate  a  loss  of  function  of  the  part, 
but  the  term  "  loss  of  function,"  as  ordinarily  employed,  means 
that  the  normal  use  of  the  portion  of  the  body  affected  is  impos- 
sible. For  example,  after  fracture  of  the  tibia  the  patient  cannot 
hear  his  weight  on  the  foot.  After  fracture  of  the  humerus  he 
cannot  hold  a  ten  pound  weight  at  arm's  length,  etc.  It  is  worthy 
of  note  thai  loss  of  function  is  usually  only  partial;  thus,  after 
fracture  of  the  fibula  alone,  the  patient  can  walk  upon  bis  beel, 
1ml  cannot  bear  his  weight  upon  the  ball  of  the  foot.  The  special 
limitations  of  function  which  follow  various  fractures  form  an 
important  part  of  the  knowledge  necessary  for  an  accurate  diag- 
nosis and  treatment  of  the  same. 

Loss  of  function  frequently  exists  without  a  fracture.  Pres- 
sure upon  contused  areas,  tensions  of  damaged  muscles  and  nerves, 
motion  of  inflamed  joint  surfaces,  and  so  forth,  may  all  cause 
pain,  and  thus  interfere  with  the  normal  uses  of  the  body.  The 
exact  limitations  of  function  can  often  be  better  determined  if 
the  patient's  attention  is  directed  away  from  the  injured  part. 
The  administration  of  an  anesthetic,  but  not  to  full  anesthesia,  is 
frequently  a  valuable  help  in  determining  loss  of  function. 

11.  General  anesthesia  is  of  great  assistance  in  the  diagnosis 
of  fractures.  The  patient  is  thereby  spared  much  pain,  the  sur- 
geon is  put  at  his  ease,  the  muscles  are  relaxed  so  that  much  less 
force  is  necessary  in  manipulation,  and  the  existence  of  positive 
signs  of  fracture  and  the  relation  of  the  fractured  ends  to  one 
another  are  made  out  with  an  accuracy  which  is  quite  impossible 
in  most  cases  if  no  anesthetic  is  employed.  Furthermore,  anes- 
thesia is  a  great  help  toward  the  reduction  of  displacement,  but  it 
should  be  borne  in  mind  that,  with  the  return  of  consciousness, 
muscular  contraction  will  again  take  place,  and  the  fragments  may 
again  be  drawn  out  of  relation. 

Treatment. — Successful  treatment  of  any  fracture  accom- 
plishes three  things: 

1.  Reposition  of  the  fragments; 

2.  Immobility  of  the  fragments;  and 

3.  Restoration  of  function. 


FRACTURES   IN   GENERAL  'MY.) 

The  patient  should  be  anesthetized  whenever  for  the  purposes 
of  diagnosis  or  reposition  of  the  fragments  the  surgeon  is  obliged 
to  use  force  or  cause  pain.  A  snap  reposition,  like  a  snap  diag- 
nosis, may  be  correct,  but  is  never  justifiable.  Before  giving  an 
anesthetic,  and  before  reducing  the  fracture  or  bandaging  the 
part,  sensation  and  motion  in  the  part  of  the  limb  beyond  the 
break  should  always  be  tested.  Otherwise  a  subsequently  observed 
paralysis  may  be  ascribed  to  the  surgeon. 

1.  The  fragments  are  best  replaced  by  manipulation  while 
traction  is  exerted  by  an  assistant. 

Impaction  between  the  fragments  should  never  be  broken  up 
if  they  are  in  correct  line.  It  should  always  be  broken  up  if  the 
alinement  of  the  fragments  is  so  bad  as  to  interfere  with  the 
proper  use  of  the  limb.  Whether  an  impaction  should  be  broken 
up  when  the  alinement  is  bad,  but  the  function  is  not  seriously 
interfered  with,  depends  upon  the  age  and  nutritive  condition  of 
the  patient,  the  probability  that  a  better  alinement  can  be  obtained, 
the  possibility  of  non-union,  etc. 

Measurements  of  the  length  of  the  injured  bone  as  compared 
with  those  of  the  opposite  side  are  valuable  as  showing  the  amount 
of  shortening  and  also  the  success  of  reduction.  Generally  speak- 
ing, if  the  shortening  is  more  than  a  half  inch  reduction  is  unsat- 
isfactory. The  fragments  have  not  been  restored  to  their  normal 
relations,  or  the  muscles  do  not  allow  them  to  remain  in  proper 
relation.  In  the  former  case  a  better  reduction  should  be  brought 
about  under  an  anesthetic.     In  the  latter  case  extension  should  be 

i 

employed. 

2.  Immobility  is  secured  by  splints  and  extension.  The  best 
splints  for  most  fractures  are  made  of  plaster  of  Paris  bandages 
molded  directly  on  the  limb.  When  dry  they  may  be  trimmed, 
if  necessary,  and  covered  with  canton  flannel  or  some  similar  mate- 
rial (Figs.  174  and  175,  p.  382). 

3.  Restoration  of  function  can  be  aided  by  massage,  passive 
motion  of  neighboring  joints,  active  motion,  hot  bathing,  dry  heat, 
and  electricity. 

Massage  may  be  employed  with  benefit  on  the  day  following  a 
fracture,  and  every  day  afterward  until  there  is  complete  restora- 
tion of  function.  For  the  first  few  days  the  limb  should  be  rubbed 
lightly  above  and  below  the  seat  of  fracture.     Then  one  splint  may 


370      DISLOCATIONS    AND    FRACTURES    OF    THE    ARM   AND   HAND 

be  removed  to  permit  gentle  stroking  of  the  injured  portion.  After 
two  weeks  both  splints  niay  be  removed  and  more  force  employed 

in  the  rubbing.  The  splints  are  of  course  reapplied  immediately 
after  (he  treatment.  By  this  means  the  disappearance  of  the  swell- 
ing is  hastened,  the  formation  of  adhesions  is  kept  at  a  minimum, 
and  the  surgeon  is  given  an  accurate  knowledge  of  the  positions 
of  the  fragments  at  a  time  when  a  faulty  position  may  be  easily 
corrected. 

Passive  motions  of  the  neighboring  joints  should  be  made 
every  two  or  three  days,  beginning  at  the  expiration  of  a  week. 
The  patient's  sensation  is  the  best  guide  to  the  extent  of  the 
motions,  but  no  motions  should  be  made  which  will  disturb  the 
fragments. 

The  amount  of  active  motion  allowed  will  depend  upon  the 
nature  of  the  fracture.  In  general,  active  motion'  at  the  nearest 
joints  should  not  be  attempted  until  the  union  is  sufficiently  firm 
to  allow  the  surgeon  to  handle  the  injured  portion  of  the  limb 
readily  without  fear  of  displacement.  Active  motions  of  more 
distant  joints  may  be  allowed  somewhat  sooner  than  this. 

Hot  water  applications,  hot  packs,  and  baking  in  a  hot  air 
apparatus  are  powerful  stimulants  to  circulation,  and  are  service- 
able in  restoring  mobility  to  stiffened  joints  after  the  bony  union 
is  firm.  The  mobility  thus  gained  must  be  kept  up  by  massage 
and  active  and  passive  motions,  or  the  stiffness  will  be  likely  to 
recur. 

Mechanical  vibration  is  a  form  of  massage  which  is  of  very 
great  service  in  the  later  treatment  of  fractures. 

Electricity  is  employed  with  benefit  to  keep  up  the  tone  of 
muscles  grown  flabby  by  some  weeks  of  disuse,  and  also  in  cases 
in  which  the  nerves  have  been  injured  at  the  time  of  fracture  or 
afterward,  by  manipulation  or  by  pressure  caused  by  splints  or 
bony  fragments  or  callus. 

Separation  of  the  Epiphysis. — There  are  two  special  forms  of 
fracture  occurring  in  children,  viz.,  separation  of  the  epiphysis 
and  green  stick  fracture.  An  epiphyseal  separation  is  virtually 
a  transverse  fracture.  In  order  to  avoid  deformity,  and  to  favor 
the  proper  growth  of  the  bone  such  a  fracture  should  be  reduced 
most  exactly.  An  anesthetic  is  desirable  in  many  cases.  When 
such  reduction  is  accomplished  union  takes  place  very  quickly, 


FRACTURES   OF   THE   HUMERUS  371 

there  is  absolutely  no  deformity  nor  shortening  of  the  Limb,  and 
the  restoration  of  function  is  perfect. 

Green  Stick  Fracture. — A  green  stick  fracture  is  one  in  which 
the  bone  is  partly  broken,  partly  bent,  as  when  force  is  applied 
to  a  living  sprout.  It  is  not  necessary  in  all  cases  to  complete 
the  fracture.  The  rule  should  be  .to  correct  the  deformity  so  com- 
pletely that  there  is  no  tendency  for  it  to  recur  when  the  force 
of  the  surgeon's  fingers  is  removed.  Once  corrected  the  deformity 
does  not  tend  to  recur. 

Fractures  of  the  Humerus. — Fractures  of  the  humerus  are 
divided  into  those  of  the  upper  extremity,  those  of  the  shaft,  and 
those  of  the  lower  extremity.  Those  of  the  upper  extremity  of 
the  humerus  are  again  divided  into  those  of  the  anatomical  and 
those  of  the  surgical  neck  of  the  bone;  while  those  of  the  lower 
extremity  are  often  spoken  of  as  fractures  of  the  internal  condyle, 
external  condyle,  T-shaped  fractures,  etc.  The  use  of  the  X-ray 
in  the  diagnosis  of  fractures  has  shown  that  such  classifications 
have  only  a  general  value,  and  that  there  is  by  no  means  a  regular 
type  of  fracture  of  each  of  the  kinds  mentioned;  but  that,  on  the 
contrary,  the  plane  of  cleavage  may  run  in  almost  any  direction; 
it' may  be  too  irregular  to  be  spoken  of  as  a  plane  at  all,  and  that 
often  there  is  more  than  one  break,  so  that  the  bone  is  separated 
more  or  less  completely  into  three  or  more  pieces.  Hence  the 
great  importance  of  studying  each  case  by  itself.  The  use  of 
the  X-ray,  both  for  diagnosis  and  as  confirmatory  of  reduction  of 
displaced  fragments,  is  greatly  to  be  advised,  and  should  be  in- 
sisted upon  by  the  surgeon  in  all  doubtful  cases. 

In  almost  all  cases  the  fracture  is  due  to  a  fall. 

Fractures  of  the  Upper  End  of  the  Humerus. — Fracture  of  the 

upper  end  of  the  humerus  is  not  a  difficult  diagnosis  to  make 

out,  provided  the  tuberosities  are  separated  from  the  shaft  of  the 

bone.     Then,  if  the  arm  is  grasped  at  the  elbow  and  rotated  by 

the  surgeon  the  tuberosities  do  not  rotate  with  it,  and  a  certain 

diagnosis  of  fracture  can  be  made,  even  though  crepitus  is  not 

elicited.      This  fracture  has  been  spoken  of  as  fracture  of  the 

surgical  neck   of  the   humerus,    as   distinguished   from   fracture 

of  the  anatomical  neck.     In  the  latter  case,  the  tuberosities  being 

attached  to  the  shaft,  rotate  with  it.     The  diagnosis  is  then  more 

difficult.      Even  if  crepitus   is   attained,   it  may  be   simply   the 
26 


372     DISLOCATIONS   AM)    FRACTURES   OF   THE   ARM   AND   HAND 

grating  so  often  produced  by  rotation  of  the  humerus,  especially 

in  ]>eople  who  have  reached  middle  aire  and  whoso  joints  have 
suffered  previous  inflammation.  If  crepitus  can  be  obtained  by 
pushing  the  arm  directly  up  and  down,  it  is  more  significant  of 
fracture  than  if  it  is  produced  simply  by  rotation. 

The  other  customary  signs  of  fracture  are  well  marked. 
Ecchymosis  is  greater  if  the  fracture  involves  or  passes  below  the 
tuberosities  than  it  is  if  the  fracture  is  through  the  anatomical 
neck.  The  effused  blood;  directed  by  gravity  and  fascial  planes, 
is  often  most  prominent  at  the  elbow. 

There  is  about  one-half  inch  shortening,  if  the  fracture  is 
between  the  points  measured.  Crowding  the  elbow  upward  will 
sometimes  increase  the  shortening,  and  will  give  pain  at  the  frac- 
ture. 

False  point  of  motion  is  often  demonstrable,  and  if  the  frac- 
ture is  below  both  tuberosities,  there  is  often  an  inward  angulation 
of  the  shaft. 

If  the  fracture  is  impacted,  the  tuberosities  will  rotate  with 
the  shaft,  even  though  the  line  of  fracture  is  below  them.  In 
such  a  case  the  diagnosis  must  be  made  from  the  shortening,  ten- 
derness, loss  of  function,  ecchymosis,  angular  deviation  of  the 
shaft,  if  such  exists,  and  the  direct  palpation  of  the  bone  at 
the  fracture.  It  will  be  noticeably  thickened  as  compared  with 
the  opposite  side. 

Treatment. — Tn  fracture  of  the  anatomical  neck  of  the 
humerus  the  arm  should  be  supported  and  kept  close  to  the  scapula 
by  plaster  strapping  or  by  a  body  bandage  and  a  sling.  After 
ten  days  or  two  weeks,  gentle  passive  motions  should  be  made  to 
prevent  the  formation  of  firm  adhesions  in  the  joint.  If  the  bone 
fails  to  unite,  a  painful  or  much  impaired  joint  results,  and  an 
open  operation  is  necessary,  either  to  remove  the  head  of  the  bone 
or  to  fasten  it  to  the  shaft  by  sutures  or  pegs. 

In  fracture  of  the  surgical  neck  the  deformity  may  be  cor- 
rected by  the  weight  of  the  arm  if  the  hand  be  kept  in  a  sling; 
or  additional  extension  may  be  obtained  by  a  light  weight,  two  to 
five  pounds,  hung  at  the  elbow.  A  shoulder  cap  should  be  made 
from  a  plaster  of  Paris  bandage  applied  in  the  form  of  a  spica, 
including  the  shoulder  and  extending  around  the  chest  (No.  34, 
Chapter  XXI).     "When  dry,  all  of  this  bandage  should  be  cut 


FRACTURES  OP  THE  HUMERUS  373 

away  except  an  external  shoulder  cap.  This  and  a  short  internal 
splint  should  be  bandaged  in  place  by  a  soft  bandage,  and  the  hand 
placed  in  a  sling.  Massage  and  passive  motion  should  be  begun 
in  two  weeks  or  less  to  prevent  if  possible  the  adhesions  which 
often  form  in  and  about  the  joint. 

Fracture  of  the  Shaft  of  the  Humerus. — Fracture  of  the  shaft 
of  the  humerus  is  a  common  accident,  and  one  which  is  easily 
diagnosticated  by  the  false  point  of  motion,  which  can  always 
be  made  out.  The  direction  of  the  displacement  will  vary  accord- 
ing to  the  site  of  the  fracture  above  or  below  the  attachment  of 
the  deltoid  and  the  origin  of  the  brachialis  antieus. 

Essential  treatment  consists  in  the  application  of  coaptation 
splints  to  the  arm,  with  extension  at  the  elbow  to  overcome  short- 
ening, and  support  of  the  hand  in  a  sling.  As  soon  as  the  tendency 
to  deformity  or  displacement  of  the  broken  ends  is  overcome  the 
extension  may  be  omitted,  and  passive  motions  be  made  at  the 
elbow  and  shoulder.  The  hand  should  be  carried  in  a  sling  until 
firm  union  results. 

While  fracture  of  the  shaft  of  the  humerus  is  easily  and  suc- 
cessfully treated  in  most  cases,  it  is  of  all  fractures  of  the  body 
the  one  most  likely  to  result  in  non-union.  As  reasons  for  this 
may  be  mentioned  the  fact  that  the  bone  is  a  single  one  of  small 
size,  and  the  further  fact  that  the  fracture  is  usually  transverse. 
Thus  muscular  traction  may  cause  overlapping.  If  non-union 
results  the  case  should  not  at  once  be  given  up  as  hopeless,  nor  an 
immediate  operation  be  advised.  There  should  first  be  tried  abso- 
lute rest  in  a  correct  position  as  obtained  by  a  plaster  of  Paris 
splint  of  the  whole  extremity  and  shoulder,  applied  under  ether 
if  necessary.  If  no  stiffening  of  the  break  is  evident  after  two 
or  three  weeks  of  this  treatment,  the  ends  of  the  fractured  bone 
should  be  vigorously  rubbed  together  twice  a  week,  the  arm  be- 
ing kept  at  rest  in  the  intervals.  Sometimes  it  is  of  advantage 
to  omit  all  dressing,  except  the  coaptation  splints,  and  to  allow 
the  patient  to  use  the  hand  and  forearm.  This  improves  the  cir- 
culation of  the  limb,  and  if  judiciously  carried  out,  need  not 
increase  displacement  of  the  fractured  bone.  These  and  similar 
measures  calculated  to  stimulate  the  ends  of  the  bone,  while  pre- 
venting an  undue  amount  of  motion,  may  result  in  a  cure,  even 
though  union  be  delayed  for  six  months  or  more.     Should  these 


374     DISLOCATIONS   AND    FRACT1  RES   OF   THE   ARM   AND   HAND 

simpler  measures  tail,  an  incision  should  be  made,  any  soft  tissue 
which  is  found  lying  between  the  fractured  ends  of  the  bone 
should  be  removed,  the  ends  of  the  bones  should  be  freshened 
and  shaped  to  each  other  as  well  as  possible,  and  fixed  firmly  to- 
gether by  a  drill  passed  obliquely  through  both,  and  left  in  posi- 
tion for  two  or  three  weeks,  or  by  means  of  a  suture,  preferably 
of  materials  which  will  become  absorbed  in  two  weeks  or  more. 

Even  though  no  bony  union  follow  fracture  of  the  humerus,  the 
arm  is  far  from  useless. 

Another  complication  of  fracture  of  the  shaft  is  involvement 
of  the  musculospiral  nerve,  and  paralysis  of  the  extensor  mus- 
cles of  the  hand  and  fingers.  The  nerve  may  be  injured  at  the 
time  the  bone  is  broken,  or  it  may  be  pressed  upon  later  by  a 
splint,  or  it  may  be  involved  in  the  forming  callus.  To  avoid 
unpleasant  accusations,  the  surgeon  should  always  test  the  sensa- 
tion and  circulation  of  a  limb,  a  bone  of  which  has  been  broken, 
both  before  and  after  the  application  of  splints.  If  the  func- 
tion of  the  musculospiral  does  not  return  with  the  help  of  bath- 
ing, massage,  and  electricity,  the  nerve  should  be  exposed  and 
freed. 

Fracture  of  the  Lower  End  of  the  Humerus. — Fracture  of  the 
lower  end  of  the  humerus  is  very  common,  especially  in  child- 
hood. The  exact  line  of  fracture  may  extend  transversely  across 
the  bone,  or  may  separate  either  condyle,  with  or  without  the 
articular  portion ;  or  the  injury  may  be  a  still  more  complex  one. 
An  exact  diagnosis  of  injuries  about  the  elbow-joint  is  often 
impossible.  The  use  of  the  X-ray  is  of  the  greatest  benefit  under 
such  circumstances,  and  the  surgeon  for  his  own  protection,  as 
well  as  for  his  own  satisfaction  and  for  the  benefit  of  the  patient, 
should  insist  that  a  radiograph  be  taken.  The  use  of  an  anes- 
thetic is  also  of  the  greatest  assistance  in  clearing  up  the  diagno- 
sis, especially  in  determining  how  much  the  normal  motions  have 
been  interfered  with  by  the  injury.  Deformity  may  at  the  same 
time  be  overcome,  and  the  limb  placed  in  a  plaster  of  Paris  splint. 
Whatever  the  injury,  the  limb  is  usually  best  treated  with  the 
forearm  flexed  at  a  right  angle  and  held  in  a  position  midway 
between  pronation  and  supination.  Either  the  plaster  of  Paris 
or  starch  bandage  should  include  the  hand,  or  a  sling  should 
support  the  hand,  and  save  the  patient  from  the  pain  caused  by 


FRACTURES   OF   THE    HUMERUS  375 

the  constant  stretching  of  the  radial  ligaments  of  the  wrist.  The 
arm  should  be  inspected  at  least  three  times  the  first  week  and 
twice  a  week  for  a  month  or  longer.  After  the  first  week  pas- 
sive motions  (rotation  of  the  hand  and  arm,  flexion  and  extension 
of  the  forearm)  should  be  begun.  These  motions,  combined  with 
light  massage,  should  be  slight  at  first,  and  grow  more  extensive 
as  the  union  of  the  fragments  progresses. 

Deformity  following  fracture  of  the  lower  end  of  the  humerus 
is  not  uncommon,  owing  to  the  fact  that  the  lower  fragment  has 
united  at  a  vicious  angle.  Such  deformity  is  most  noticeable 
when  the  arm  is  fully  extended,  and  the  forearm  and  hand  will 
then  appear  to  be  bent  abnormally  backward  or  to  one  side.  If 
the  deformity  is  not  too  great,  and  especially  if  the  motions  of  the 
elbow  are  free  and  painless,  operative  interference  should  be 
advised  against. 

Another  common  after-effect  is  limitation  of  flexion  and  ex- 
tension. Flexion  is  usually  affected  to  a  greater  extent  than 
extension.  If  motion  in  the  joint  is  prevented  by  swelling  merely, 
this  may  be  overcome  by  use  of  the  arm  and  massage.  But  in 
other  cases  there  is  a  mechanical  obstruction  to  flexion  or  exten- 
sion, which  will  not  yield  to  such  simple  measures.  Under  such 
circumstances  an  anesthetic  (preferably  nitrous  oxid)  should  be 
given,  since  if  the  motion  is  limited  by  adhesions,  these  may  be 
broken  up.  In  many  instances  the  limitation  of  motion  is  due 
to  the  formation  of  callus  and  new  bone  at  or  near  the  line  of 
fracture ;  iso  that  the  function  of  the  joint,  instead  of  increasing, 
may  grow  less  as  the  weeks  go  by.  This  bony  irregularity  is  due 
to  imperfect  reduction.  If  recognized  early  by  an  X-ray  examina- 
tion it  may  be  corrected  by  manipulation.  At  a  later  date,  if  the 
limitation  of  motion  is  still  considerable,  sufficient  say  to  pre- 
vent the  patient  from  putting  the  hand  up  to  the  head,  and  con- 
tinues in  spite  of  a  thorough  course  of  treatment  by  massage, 
and  active  and  passive  motions,  extending  over  several  weeks,  and 
if  under  an  anesthetic  the  forearm  cannot  be  flexed  much  beyond 
the  point  to  which  it  can  be  flexed  without  the  anesthetic,  an 
operation  is  indicated.  Possibly  the  bony  outgrowth  may  be 
chiseled  away,  so  that  an  increase  of  flexion  is  possible.  If  anky- 
losis seems  inevitable,  the  surgeon  must  choose  between  fixing 
the  elbow  at  the  most  favorable  angle,  a  little  less  than  a  right 


376      DISLOCATIONS    AND   FRACTURES   OF   THE   ARM   AND    HAM) 

angle,  or  resecting  the  elbow-joint.  The  effect  of  this  is  to 
give  a  fibrous  flail-like  painless  j < > i  1 1 1  a1  the  elbow,  which  enables 
the  patient  to  do  far  more  with  the  hand  and  arm  than  is  pos- 
sible with  a  tixed  joint,  no  matter  al  whal  angle. 

Fractures  of  the  Ulna  and  Radius.— Fracture  of  the  Ole- 
cranon Process  of  the  Ulna. — Fracture  of  the  olecranon  is  due  to 


X     g 


E  O 

*  S 


<  s  S 


x  w 


>H      & 


falls  upon  the  elbow.  The  diagnosis  is  easily  made,  since  the 
olecranon  is  movable  upon  the  ulna,  often  with  crepitus.  The 
fragments  may  be  separated  in  flexion  of  the  forearm,  so  that 
the  injury  is  best  treated  by  placing  the  extended  arm  on  a  splint 


FRACTURES  OF  THE  ULNA  AND  RADIUS 


377 


for  ten  days  or  two  weeks,  and  then  beginning   possible   motion 
to  prevent  adhesions  in  the  elbow-joint. 

Fracture   of   Head   of   Radius. — Fracture  of   the   head   of   the 
radius,  or  of  its  neck,  is  due  to  falls  upon  the  hand  (Figs.   172 


Fig.  173. — Same  Subject  as  Fig.  172.      Radiograph  giving  lateral  view  of  fractured 

radius. 


and  173).  The  rarity  of  this  fracture  is  a  matter  for  surprise. 
Doubtless  it  has  often  been  overlooked,  and  the  diagnosis  made 
of  sprain  of  the  elbow-joint  or  fracture  of  the  external  condyle 
of  the  humerus. 

The  symptoms  of  fracture  of  the  head  of  the  radius  are  the 
general  ones  of  fracture  everywhere.  Pain  is  also  produced  by 
crowding  upward  the  palm  of  the  overextended  hand ;  pronation 
and  supination  are  also  extremely  painful,  and  may  be  impossi- 
ble. This  fact,  together  with  the  fact  that  the  maximum  swell- 
ing and  tenderness  is  below  the  plane  of  the  elbow- joint,  and  the 
further  fact  that  pressure  upon  the  two  condyles  does  not  elicit 
pain,  will  serve  to  differentiate  an  uncomplicated  fracture  of 
the  head  of  the  radius  from  fracture  of  the  external  condyle. 
An  X-ray  examination  is  often  necessary  to  establish  the  diag- 
nosis. 


378      DISLOCATIONS   AND   FRA(Tl  IIKS    oK    THE    ARM    AND    HAND 

Treatment. — Deformity  should  be  overcome  it  possible3  and 
the  forearm  immobilized  at  an  angle  of  ninety  degrees,  midway 
between  pronation  and  supination,  for  two  weeks.  Then  passive 
motions,  both  llexiun  and  extension  and  rotation  (very  gentle), 
should  he  commenced  and  gradually  increased,  the  arm  heing 
kept  in  a  sling  for  at  least  two  weeks  longer.  In  some  cases  per- 
manent limitation  of  motion,  especially  of  pronation  and  supina- 
tion, makes  it  necessary  to  remove  some  of  the  displaced  hone. 

Fracture  of  the  Shaft  of  the  Ulna  or  Radius. — Fractures  of  the 
ulna  or  radius,  or  of  both  of  these  bones  occurring  in  the  shaft, 
are  usually  made  out  without  difficulty.  The  ulna  lies  so  close 
to  the  skin  that  a  break  in  it  can  he  easily  determined  by  direct 
palpation,  while  the  attachment  of  the  hand  to  the  radius  helps 
in  the  diagnosis  of  a  fracture  of  this  bone,  in  cases  in  which  the 
ulna  is  not  broken.  The  hand  and  lower  fragment  of  the  radius 
can  be  moved  independently  of  the  ulna  to  a  short  distance,  and 
hence  a  false  point  of  motion  in  the  radius  can  be  made  out  almost 
as  easily  as  it  can  be  in  the  humerus  or  femur.  When  both 
bones  are  broken  the  diagnosis  is  extremely  simple  in  adults.  In 
young  children  it  sometimes  happens  that  one  or  both  bones  are 
partially  broken  as  the  branch  of  a  living  tree  breaks  on  one  side 
and  bends,  hence  the  term  "green  stick"  fracture  (see  p.  371). 

Treatment. — If  a  green  stick  fracture  exists,  in  order  to  get 
the  bone  to  remain  in  a  correct  position,  it  is  often  necessary  to 
overcorrect  the  deformity.  In  so  doing,  the  remaining  portion 
of  bone  may  be  broken  through.  This  in  itself  is  not  a  serious 
accident,  and  is  preferable  to  allowing  the  deformity  to  remain 
only  partially  reduced. 

In  other  respects  fractures  in  the  middle  of  the  forearm  are 
easily  treated.  When  the  deformity  has  been  overcome  by  manipu- 
lation, the  hand  should  be  placed  midway  between  pronation  and 
supination,  and  the  bone  should  be  kept  quiet  by  means  of  light 
anterior  and  posterior  splints,  or  a  light  plaster  of  Paris  bandage. 
If  the  plaster  is  fresh  and  is  applied  before  it  has  time  to  set  there 
is  no  need  for  such  a  bandage  to  be  more  than  an  eighth  or  a 
twelfth  of  an  inch  in  thickness.  The  heavy  cumbrous  bandages 
which  are  sometimes  applied  are  by  their  very  weight  not  only 
uncomfortable,  but  injurious  to  the  patient. 

The  position  of  the  hand  has  been  a  matter  of  considerable 


FRACTURES   OF  THE    ULNA   AND   RADIUS  379 

dispute.  Some  writers  have  said  that  the  hand  should  be  fully 
supiuated  in  order  to  prevent  the  callus  from  uniting  the  radius 
and  ulna.  They  have  stated  that  the  bones  were  most  widely 
separated  in  extreme  supination.  Others  have  denied  this,  claim- 
ing that  the  separation  is  greatest  in.  a  position  between  pronation 
and  supination.  An  examination  of  any  cadaver,  or  of  the  fore- 
arm in  life  by  means  of  the  X-ray,  will  show  that  the  distance 
between  the  bones  is  almost  the  same  whether  the  hand  be  held 
two-thirds  supinated  or  be  fully  supinated.  Since  this  is  the  case, 
the  comfort  of  the  patient  demands  that  the  hand  be  placed  with 
the  thumb  directly  upward,  the  elbow  being  flexed  at  a  right  angle. 
This  is  the  natural  position  of  the  forearm,  and  to  hold  the  hand 
for  a  long  time  fully  supinated  when  the  forearm  is  flexed  at  a 
right  angle  is  a  tiresome  procedure  in  health,  and  well-nigh  impos- 
sible if  the  arm  is  broken. 

In  fracture  of  the  radius  there  is  a  chance  of  the  interposi- 
tion of  muscle  or  fibrous  tissue  between  the  broken  ends,  while 
the  numerous  strong  muscles  cause  overlapping  if  both  bones  are 
broken.  The  possibility  of  non-union  should  always  be  borne  in 
mind  if  crepitus  is  not  elicited  when  the  fracture  is  fresh,  or  if 
there  is  still  motion  at  the  line  of  fracture  in  a  month  or  six 
weeks.  But  the  surgeon  should  not  be  too  impatient  nor  turn 
too  quickly  to  an  open  operation,  the  results  of  which  are  by  no 
means  invariably  good.  Moreover,  it  sometimes  happens  that 
union  which  has  been  delayed  for  six  or  eight  weeks  will  never- 
theless take  place  spontaneously  under  the  more  favorable  condi- 
tions of  massage,  and  an  occasional  rubbing  together  of  the  ends 
of  the  bone. 

If  both  radius  and  ulna  are  broken,  and  non-union  results, 
pronation  and  supination  of  the  hand  are  impossible.  If  a  single 
bone  is  broken,  pronation  and  supination  is  at  first  impossible,  but 
later  is  possible  to  a  certain  extent,  even  though  only  a  fibrous 
union  exist  between  the  fractured  ends. 

Pronation  and  supination  are  also  limited  by  angular  de- 
formity of  one  or  both  bones,  and  are  absolutely  prevented  by  a 
bony  union  of  radius  to  ulna.  A  complete  crossed  union  of  radius 
and  ulna,  i.  e.,  the  union  of  the  lower  fragment  of  the  ulna  with 
the  upper  fragment  of  the  radius,  and  vice  versa,  probably  never 
occurs,  but  any  bony  fusion  of  these  bones  is  equally  destructive 


380      DISLOCATIONS   AND   FRACTURES   OF  THE  ARM  AND   HAND 

of  the  function  of  rotation  of  the  hand,  and  is  an  absolute  indica- 
tion for  operation.  To  prevent  such  fusion,  some  authors  advise 
the  use  of  splints,  the  center  of  each  of  which  is  elevated  in  a 
ridge,  intended  to  press  between  the  radius  and  ulna,  so  as  to 
keep  the  bones  apart.  This  device  is  theoretical  rather  than  prac- 
tical. 

Fracture  of  the  Lower  End  of  the  Radius  (Colles's  Fracture). — 
Fracture  just  above  the  wrist-joint,  always  involving  the  radius 
and  sometimes  the  tip  of  the  ulna,  and  known  as  Colles's  fracture, 
after  the  surgeon  who  accurately  described  it,  is  one  of  the  com- 
monest tinctures  which  the  surgeon  is  called  upon  to  treat.  The 
study  of  radiographs  of  this  injury  is  most  instructive.  Such 
pictures  show  that  the  line  of  fracture  may  extend  in  almost  any 
direction.  The  lower  end  of  the  radius  may  be  broken  into  sev- 
eral pieces,  or  there  may  be  a  single  break  either  involving  the 
joint  or  extending  across  the  bone  in  a  more  or  less  oblique  direc- 
tion wholly  above  the  joint.  The  radiographs  also  show  that  the 
lower  end  of  the  ulna  is  involved  in  about  a  third  of  the  cases, 
a  fact  which  is  rarely  made  out  clinically,  and  which  has  little 
bearing  on  the  treatment. 

In  Colles's  fracture  the  lower  end  of  the  radius  may  be  dis- 
placed in  any  direction.  The  common  displacement  is  upward 
and  backward.  This,  with  the  fact  that  the  plane  of  the  articular 
surface  is  often  bent  a  little  backward,  causes  wdiat  is  known  as  a 
silver  fork  deformitv,  the  hand  assuming  something  of  the  curves 
of  an  ordinary  table  fork.  The  other  signs  of  this  fracture  are 
a  displacement  upward  of  the  styloid  process  of  the  radius  when 
compared  with  the  styloid  process  of  the  ulna,  tenderness,  ecchy- 
mosis,  and  possibly  abnormal  motion  and  crepitus. 

Treatment. — Owing  to  the  breadth  of  bone  and  its  spongy 
character,  and  to  the  fact  that  the  injury  is  received  usu- 
ally by  a  fall  upon  the  hand,  the  lower  fragment  of  the  radius 
is  often  impacted  in  the  shaft.  False  motion  and  crepitus  will 
then  be  absent,  but  an  abnormal  thickening  and  irregularity  of 
the  bone  may  mark  the  plane  of  fracture.  If  no  deformity  exists, 
there  is  no  need  of  breaking  up  this  impaction.  The  injury  is 
much  simplified  thereby,  and  in  two  or  three  weeks  the  patient 
will  begin  to  have  free  use  of  his  hand.  Such  a  fortunate  condi- 
tion is  rare.     The  impacted  fragment  is  almost  always  set  into 


FRACTURES  OF  THE   RADIUS  381 

the  shaft  at  a  false  angle,  hence  the  necessity  for  breaking  up  the 
impaction  and  restoring  the  normal  relation  of  the  parts.  This 
can  best  be  done  under  the  influence  of  a  general  anesthetic, 
nitrous  oxid  being  well  suited  to  the  purpose.  It  is  extremely 
important  that  any  existing  deformity  should  be  thoroughly  re- 
duced. Under  no  circumstances  should  the  surgeon  trust  to  pres- 
sure obtained  by  splints  to  reduce  the  deformity.  The  strength 
of  the  structures  forming  the  wrist- joint  and  the  nearness  of  the 
plane  of  fracture  to  the  joint  itself  make  it  almost  impossible 
to  overcome  deformity  by  pressure,  and  a  firm  pressure  easily 
causes  necrosis  of  the  skin  overlying  the  back  of  the  wrist.  If 
impaction  has  been  broken  up  and  the  deformity  has  been  thor- 
oughly reduced,  there  will  be  little  tendency  to  recurrence  except 
through  muscular  contractions.  To  avoid  this  the  hand  should 
be  kept  at  rest  by  anterior  and  posterior  plaster  splints,  extend- 
ing at  least  to  the  metacarpophalangeal  joints.  In  difficult  cases 
these  should  be  applied  while  the  patient  is  thoroughly  anes- 
thetized   and   muscular    contraction   eliminated. 

If  there  is  any  doubt  as  to  the  diagnosis  and  perfect  reduc- 
tion cannot  be  obtained  and  kept  up,  a  good  X-ray  picture  of  the 
injury  in  the  anteroposterior  and  lateral  planes  should  be  insisted 
upon.  If  the  patient  refuses  this  aid  to  diagnosis  and  treatment, 
there  will  be  little  ground  upon  which  to  rest  a  suit  for  malprac- 
tice in  case  the  function  of  the  hand  is  not  fully  restored. 

A  great  many  different  forms  of  splints  have  been  advocated 
for  this  injury.  Good  results  have  been  obtained  with  all  of 
them,  and  indeed  in  many  cases  with  no  splint  whatever,  the  hand 
being  merely  carried  in  a  sling  with  a  broad  strap  of  rubber  plas- 
ter about  the  wrist  to  support  the  broken  bone.  Others  have 
advocated  carrying  the  forearm  or  hand  in  a  sling,  the  edge  of 
which  reaches  only  to  the  line  of  fracture,  and  thus  permits  grav- 
ity to  prevent  the  recurrence  of  the  deformity.  Such  an  appa- 
ratus is  needlessly  simple  and  places  too  great  responsibility  upon 
even  an  intelligent  patient.  The  advantages  claimed  for  it  are 
the  avoidance  of  stillness  in  the  wrist-joint  and  a  hastening  of 
the  time  of  repair  by  means  of  massage  and  passive  motion.  These 
advantages  are  very  great,  especially  in  persons  past  middle  age, 
but  they  can  be  readily  obtained  by  the  frequent  removal  of  well 
fitting  anterior   and   posterior   splints,    while   the   splints   protect 


382      DISLOCATIONS   AND   FRACTURES   OF  THE   ARM    AND    HAND 

the  patient  against  possible  accidenl  and  are  Ear  more  comfortable 
than  the  sling  alone.     They  are  made  as  follows: 

A  two  or  three  inch  crinoline  gypsum  bandage  should  be  wet 
and  drawn  back  and  forth  on  a  board  or  marble  slab  for  a  dis- 
tance of  fifteen  inches  until  twelve  or  fifteen  thicknesses  are 
made  to  overlie  each  other.  They  are  thoroughly  rubbed  together. 
A  second  bandage  is  used  to  make  a  second  strap  splint.  The 
fracture  is  reduced,  and  the  hand  of  the  patient  put  in  whatever 
position  of  flexion,  extension,  abduction3  or  adduction  best  keeps 
the  reduced  radial  fragment  in  correct  position.  The  skin  is 
anointed,  and  the  moist  plaster  strap  splints  arc  then  applied  and 
approximated  with  a  gauze  bandage  (Figs.  174  and  175).  The 
hand  and  forearm  are  held  for  ten  or  fifteen  minutes  till  the 
plaster  has  partially  set.  In  this  manner  two  light  rigid  splints  are 
obtained  which  are  accurately  molded  to  the  part,  and  which  can 
be  applied  and  removed  at  pleasure,  and  which  fit  far  better  than 
any  wooden  or  metal  splints  can  possibly  do.  In  three  days  the 
splints  should  be  removed  for  light  massage,  and  reapplied.  This 
treatment  should  be  repeated  every  two  or  three  days  until  three 
weeks  have  passed.     After  the  first  week  gentle  passive  motion 


Fig.  174. — Molded    Gypsum    Splints  for   Fracture  of  the  Lower  End  of  the 
Radius.     Photographed  after  removal  from  the  limb. 


may  be  made  at  the  wrist,  and  the  fingers  flexed  and  extended 
by  passive  motions  several  times.  Tf  the  deformity  caused  by  the 
fracture  has  been  fully  reduced  at  the  start,  an  arm  treated  in 
the  manner  described  will  be  pretty  nearly  well  in  three  weeks. 
There  will  be  no  pain  and  very  little  tenderness  and  swelling  of 


FRACTURES   OF  THE   RADIUS 


383 


the  wrist,  and  the  patient  may  be  allowed  to  go  without  a  splint 
and  to  begin  active  motions  of  his  hand  while  continuing  daily 
bathing  and  massage,  and  resting  the  forearm  and  hand  in  a  sling 
when  he  is  not  using  it 


Cases  which  give  trouble  are  those  in 


Fig.  175. — Same  Splints  Applied.     This  position  of  the  hand  is  desirable  in  many 
cases,  to  prevent  recurrence  of  deformity. 

which  the  deformity  is  not  thoroughly  reduced  soon  after  the 
accident. 

Cases  of  Old  Colles's  Fracture — The  surgeon  is  often  called 
upon  to  treat  cases  of  Colles's  fracture  in  which  the  injury  oc- 
curred some  weeks  or  possibly  months  previous.  Under  such  cir- 
cumstances the  first  question  to  be  answered  is  the  desirability 
of  an  attempt  at  reduction  of  any  existing  deformity.  The 
patient  will  complain  either  of  pain  or  of  limitation  of  motion 
or  of  deformity,  possibly  all  three.  It  is  hard  to  say  in  just  how 
long  a  time  the  union  between  the  fragments  will  become  so  firm 
that  it  will  not  be  possible  to  separate  them  without  a  cutting 
operation.  This  will  depend  to  a  considerable  degree  upon  the 
amount  of  impaction  produced  by  the  injury.  In  doubtful  cases 
it  is  better  to  give  the  patient  an  anesthetic  and  to  make  an  attempt 
to  reduce  existing  deformity,  even  if  it  does  not  succeed.  It  is 
a  satisfaction  to  the  patient  to  know  that  a  fair  attempt  has  been 
made  to  reduce  the  deformity  without  an  operation,  and,  more- 
over, while  under  an  anesthetic,  adhesions  between  the  various 
bones  of  the  wrist  may  be  broken  up,  and  thus  a  greater  amount 
of  movement  be  obtained.  In  considering  the  question  of  an  open 
operation,  the  accessibility  of  the  radius  and  the  probability  of 


384      dislocations   AND   FRACTURES   OF  THE  ARM  AXD   HAND 

a  reduction  of  the  deformity  are  the  favoring  conditions,  while 
the  scar  and   the  risks   incidenl   to  operations  upon   bones,  espe- 


Fig.  17G. — Old  Fracture  of  Radius  (Colles's)  -with  Marked  Deformity,  but  ■ 

Good  Use  of  Hand. 

cially  in  the  vicinity  of  a  joint,  are  to  be  considered  as  against 
operation. 

The  extreme  deformity  of  an  old  unreduced  fracture  of  the 
radius  is  shown  in  Figure  170.  Yet  this  patient  had  good  use 
of  the  hand. 

Fracture  of  the  Carpus. — Fracture  of  one  or  more  carpal 
bones  is  not  a  very  common  accident.  It  has  to  be  differentiated 
from  sprain.  In  a  recent  state  this  diagnosis  cannot  usually  be 
made  without  the  help  of  the  X-ray.  Later  the  marked  limitation 
of  motion,  pain,  and  abnormal  thickness  of  some  portion  of  the 
wrist  may  suggest  the  true  diagnosis.  The  os  magnum  and  semi- 
lunar bones  are  most  often  broken. 

The  treatment  is  the  same  as  that  of  a  severe  sprain.  If  a 
portion  of  a  bone  is  so  displaced  as  to  interfere  with  motion,  it 
should  be  removed. 

Fracture  of  a  Metacarpal. — Fracture  of  one  or  more  of 
the  metacarpals  is  a  very  common  injury.  It  results  almost  always 
from  blows  with  the  fist,  the  force  coming  against  the  knuckle — 
that  is,  against  the  head  of  the  metacarpal.     The  line  of  fracture 


FRACTURE   OF    A    PHALANX 


M 


is  usually  just  above  the  head  of  the  bone,  although  it  may  be 
higher  up.  There  is  almost  invariably  an  anterior  displacement 
of  the  distal  fragment,  thus  causing  a  depression  of  the  knuckle 
at  the  back  of  the  hand.  This  looks  at  first  glance  like  a  dislo- 
cation of  the  phalanx  until  one  considers  that  the  knuckles  are 
formed  entirely  by  the  metacarpals,  if  the  fingers  are  flexed. 

If  the  injury  has  been  recently  received  the  diagnosis  is  easy, 
characteristic  signs  of  pain,  false  point  of  motion,  and  crepitus 
being  present. 

The  deformity  is  best  reduced  in  most  cases  by  flexing  all 
the  fingers  over  a  ball  of  yarn  or  a  gauze  bandage  placed  in  the 
hollow  of  the  palm  (Fig.  177).  The  fingers  should  be  strapped 
or  bandaged  in  this  position,  and  the  dressing  should  be  removed 
for  bathing  and  massage  two  or  three  times  a  week.     Union  takes 


Fig.  177. — Fracture  of  Second  Right  Metacarpal.  Deformity  corrected  by 
flexing  the  hand  over  a  bandage  held  in  the  palm,  with  adhesive  plaster  strap- 
ping. 

place  in  these  small  bones  very  rapidly,  and  in  young  subjects 
two  weeks  is  generally  sufficient  to  produce  a  callus  strong  enough 
to  prevent  displacement.  The  bandage  may  then  be  omitted,  and 
the  patient  simply  cautioned  against  severe  use  of  the  hand  for 
two  or  three  weeks  more. 

Fracture  of  a  Phalanx. — In  fracture  of  the  first  phalanx 
it  is  sometimes  difficult  to  prevent  recurrence  of  the  deformity, 


186      DISLOCATION'S    AND    FRACTURES    OF   THE    ARM    AM)    HAND 

owing  in  the  constanl  pull  of  the  anterior  and  posterior  tendons, 
and  the  further  fact  thai  the  weh  between  the  fingers  prevents  the 
application  of  a  circular  bandage.  This,  of  course,  does  not  apply 
to  the  thumb.  It  is  the  fifth  finger  in  which  the  first  phalanx  is 
most  often  broken,  on  account  of  its  small  size  and  exposed  position. 
It  should  he  treated  on  a  splint,  preferably  of  tin,  curved  to  fit 
three  sides  of  the  finger  and  hand.  (Cf.  Fig.  211,  p.  426.)  The 
deformity  may  be  overcome  by  allowing  the  splint  to  extend  be- 
yond the  end  of  the  finger,  and  by  making  extension  by  means 
of  longitudinal  strips  of  plaster  fastened  to  the  finger  and  reach- 
ing out  beyond  it  to  the  end  of  the  splint.  Counterextension  to 
hold  the  splint  in  place  is  obtained  by  similar  adhesive  straps 
about  the  wrist. 

Fracture  of  the  second  or  third  phalanx  is  easily  treated.  The 
pull  upon  the  distal  fragment  is  slight,  and  the  deformity  may  be 
kept  down  by  winding  rubber  plaster  around  the  finger  while 
extension  is  being  made  by  an  assistant. 

COMPOUND   FRACTURES 

Compound  fractures  of  the  upper  extremity  should  be  treated 
from  the  very  first  aseptically,  if  possible.  If  the  materials  for 
a  thorough  cleansing  of  the  wound  are  not  at  hand,  a  compress 
and  bandage  should  be  applied  and  one  or  two  splints  to  keep 
the  parts  quiet  until  preparations  can  be  made  for  a  proper  surgi- 
cal dressing.  When  the  wound  has  been  cleansed  and  drained 
and  the  deformity  reduced,  the  treatment  of  the  fracture  does  not 
differ  materially  from  that  of  a  simple  fracture,  provided  that 
no  suppuration  ensues.  The  splints  should  be  so  arranged  that 
they  may  be  easily  removed  to  permit  dressing  of  the  wound,  or 
a  window  may  be  cut  for  this  purpose.  If  the  wound  heals  asep- 
tically, a  longer  time  is  required  for  bony  union  than  is  the  case 
with  simple  fractures.  Hence  massage  and  passive  motion  cannot 
be  begun  usually  until  the  third  week. 

Suppuration  occurring  in  a  compound  fracture  will  show  itself 
locally  by  increased  edema  and  tenderness  near  the  wound  and 
a  discharge  of  pus ;  or  if  the  discharge  is  interfered  with,  by 
extension  of  the  pain  up  the  arm,  swelling  and  tenderness  of  the 
regional  lymph-glands  above  the  elbow  or  in  the  axilla,  and  by  the 
general  symptoms  of  fever,  headache,  and  malaise.     These  gen- 


CRUSHED    FJNCKWS 


3S7 


eral  svmptoms  arc.  naturally  more,  noticeable  in  cases  of  compound 
fracture  of  the  larger  bones,  but  they  also  exist  in  fracture  of 
the  hand  and  fingers  with  infection.  The  local  signs  are  usually 
sufficient  to  show  the  surgeon  whether  repair  is  progressing  favor- 
ably, but  it  is  well  to  note  the  general  symptoms  even  in  these 
minor  forms  of  fracture. 

Crushed  Fingers. — The  typical  case  of  compound  fracture 
in  which  ambulant  treatment  is  demanded  is  a  crush  or  cut  of  one 
or  more  fingers  (Fig.  178).     The  treatment  to  be  followed  in  such 


Fig.    178. — Compound    Fracture   of  the   Second   Phalanx   of  Forefinger. 

A  simple  case. 


a  case  is:  Cleansing  of  the  skin  with  soap  and  hot  water,  turpen- 
tine, and  either  alcohol  or  ether;  cleansing  of  the  wound  with  sa- 
line irrigation  and  sponging;  control  of  hemorrhage  by  pressure  or 
ligature ;  inspection  of  the  wound ;  removal  of  any  foreign  sub- 
stance and  of  detached  bits  of  bone ;  adjustment  of  the  fractured 
bone,  and  suture  with  chromic  gut  if  the  fragments  cannot  be  kept 
in  place  by  splints.  Whether  the  wound  is  sutured  or  drained  will 
depend  upon  circumstances.  The  circulation  of  the  hand  is  so  good 
that  compound  fractures  often  heal  without  suppuration ;  "but  as 
27 


388      DISLOCATIONS    AND    FRACTURES    OF   THE    ARM    AND    HAND 


rubber  tissue  drains  do  no1  cause  pain  <>r  irritate,  their  use  is  to  be 
recommended  in  this  class  of  wounds.  They  should  be  removed 
in  two  days,  and  not  reinserted  if  there  are  no  signs  of  infection. 
The  skin  sutures  should  he  of  fine  plain  catgut  or  of  very  fine  silk. 
They  should  not  he  placed  too  close  together,  since  there  is  con- 
siderable oozing  of  blood  and  serum  for  a  day  or  two.  The  hand 
and  fingers  should  he  dressed  with  dry  sterile  gauze  or  with  gauze 
moistened  with  some  mild  antiseptic,  such  as  borolyptol,  1 :  10, 
or  creolin,  1 :  200,  and  placed  on  a  palmar  splint.  Individual 
splints  to  the  fingers  are  not  usually  needed.  A  moist  dressing 
favors  the  escape  of  secretions  from  the  wound  and  adds  greatly 
to  the  comfort  of  the  patient.  It  should  not  be  covered  by  oil-silk 
or  anything  which  prevents  evaporation,  but  should  be  wet  sev- 
eral times  a  day  with 
sterile  water.  Never 
use  carbolic  acid  for 
a  continuous  wet 
dressing. 

If  the  fingers  are 
badly  crushed  or  torn, 
nice  judgment  is  often 
needed  to  get  the  very 
best  result  for  the  pa- 
tient. The  temptation 
is  great  to  amputate 
and  stitch  up  the 
wounds  completely. 
The  neatness  of  a 
stump  covered  by  well 
shaped  flaps  appeals  to 
the  surgeon,  but  not  to 
the  patient,  whose  at- 
tention is  wholly  fixed 
on  the  lost  member. 
The  extra  time  re- 
quired for  complete 
cure  is  not  considered 
by  most  patients,  if  a  longer  finger  is  thereby  secured.  It  is 
true  that  some  laborers  find  a  stiff  finger,  either  flexed  or  ex- 


Fig.  179.  —  Injuries  to  Fingers  from  Contact 
with  a  Buzz-saw.  Compound  fracture,  com- 
pound dislocations,  and  traumatic  amputation. 


AMPUTATION   OF   A   FINGER 


389 


tended,  so  much  in  the  way  that  they  ask  to  have  it  removed. 
The  finger  in  such  cases  is  generally  the  middle  or  ring  finger^ 
in  which  there  is  ankylosis  of  the  first  phalangeal  joint  and  loss 
of  the  long  flexor  tendon.  ISTo  one  ever  asks  to  have  his  thumb 
shortened  for  ankylosis.  The  fact,  therefore,  that  a  useless  finger 
is  sometimes  voluntarily  sacrificed  has  a  very  limited  application 
to  the  treatment  of  traumatisms  of  the  fingers. 

It  is  far  better  to  pursue  a  conservative  course,  and  never  to 
sacrifice  a  flap  of  skin,  no  matter  how  slender  its  attachments, 
which  can  be  used  to  cover  a  bone,  and  never  to  remove  a  phalanx 
which  can  be  covered  or  nearly  covered  by  normal  skin.  If  only 
the  base  of  a  phalanx  is  left,  it  is  better  to  remove  it  in  order  to 
avoid  tenderness  in  the  stump. 

There  are  many  recorded  instances  of  the  reattachment  of  a 
finger  or  part  of  a  finger  which  was  almost  severed  from  the  hand 
by  a  traumatism.  Such  a  case  is  shown  in  Figure  179.  A  buzz- 
saw  wounded  the  sec- 
ond digit,  disjointed 
the  terminal  phalanx 
of  the  third,  dividing 
most  of  the  soft  parts, 
amputated  the  fourth, 
and  disjointed  the  ter- 
minal phalanx  of  the 
fifth,  while  the  soft 
parts  of  this  finger 
were  stripped  from  the 
middle  phalanx  and  di- 
vided by  spiral  cuts 
which  almost  encircled 
the  finger.  Measured 
at  right  angles  to  the 
cuts,  the  undivided 
pedicle  was  about  one- 
third  of  an  inch  wide. 
The     wounds     were 

Stitched  loosely  and  the  Fig.  180. — Amputation  through  the  Metacar- 
hand  kept  Upon  a  Splint  pophalangeal    Joint.     The    photograph   taken 

some  vears  later,  shows  the  permanent  wide  gap 
and  dressed  daily  With  between  the  remaining  fingers. 


300     DISLOCATIONS   AND    FRACTURES   "1     fHE    ARM    AND   HAND 


Fig.  1S1.  —  Amputation  of  the 
Fourth  Right  Digit  with  the 
Head  of  tiii:  Metacarpal  Bone. 


to  cover  the  end  of  the  bone, 
a  racket  shaped  flap,  prefer- 
ably from  the  palmar  sur- 
face, is  best.  But,  whatever 
the  end  of  the  stump  at  first, 
it  invariably  becomes  smooth 
and  rounded  from  constant 
use.  The  chief  point,  there- 
fore, is  to  have  the  flaps  long 
enough  so  that  the  skin  may 
move  easily  over  the  bone. 
Tendons  and  nerves  should 
be  cut  off  short.  Horsehair 
is  an  excellent  suture  mate- 
rial  for   the   skin.      A   few 


moisl  gauze.  The  pho- 
tograph was  made  the 
day  after  injury.  Af- 
ter four  weeks'  con- 
servative treatment, 
the  only  loss  was  the 
terminal  phalanx  of 
the  third  digit  and  a 
small  portion  of  the 
skin  of  I  he  fifth. 

AMPUTATION   OF  A 
FINGER 

In  amputating  a 
finger,  if  there  is  plen- 
ty of  skin  with  which 


Fig. 


182. — Same  Subject  as  Fig.  181,  Pos- 
terior View. 


AMPUTATION  OF  A  FINGER 


391 


hairs  twisted  together, 
and  then  doubled  and 
allowed  to  twist  on 
themselves,  make  an 
excellent  drain.  Tlii 
should  be  passed  from 
side  to  side  cf  the  fin- 
ger, between  the  shin 
flaps  and  the  end  of 
the  bone,  to  permit  the 
escape  of  serum  and 
blood.  If  suppuration 
is  feared,  a  wet  dress- 
ing is  preferable.  A 
small  amount  of  sup- 
puration can  usually 
be  overcome  by  irriga- 


Fig.  184.- 


-Posterior  View  of  Same  Subji 
Fig.  183. 


Fig.  183. — Amputation  of 
Two  Central  Fingers 
with  their  Metacar- 
pals. The  photograph 
taken  many  years  later 
shows  the  approximation 
of  the  remaining  fingers, 
as  well  as  the  great  de- 
velopment of  the  little 
finger. 


tion  through  the  drain 
openings  with  peroxid 
of  hydrogen  and  water, 
1:6,  without  entire 
separation  of  the  flaps. 
If  amputation  is  to 
be  performed  as  high 
up  as  the  metacarpo- 
hahmgeal  joint,  the 
surgeon  must  decide 
whether  or  not  he  will 
remove    some    portion 


392      DISLOCATIONS    AND   FRACTURES    OF   THE   ARM   AND   HAND 

of  tlic  metacarpal  bone.  The  strongest  hand  is  gained  by  leaving 
it  intact;  so,  if  appearance  is  not  to  be  considered,  the  decision 
should  be  to  leave  the  whole  metacarpal  (Fig.  180). 

The  deformity  caused  by  the  loss  of  the  finger  is,  however, 
less  conspicuous  if  the  head  of  the  metacarpal  is  removed  (Figs. 
181  and  182).  While  this  is  true  for  a  single  metacarpal  in  the 
center  of  the  hand,  it  is  an  open  question  whether  the  heads  of 
the  third  and  fourth  metacarpals  should  be  removed  for  esthetic 
considerations,  since  a  depression  thus  caused  would  be  very  con- 
spicuous, as,  indeed,  is  the  deformity  no  matter  what  the  treatment. 

Another  plan  is  the  removal  with  the  phalanx  of  the  greater 
portion  of  the  metacarpal,  or  even  the  whole  bone.  This  is  prob- 
ably the  besl  method  to  pursue  if  the  fifth,  or  fourth  and  fifth, 
fingers  are  lost,  since  in  this  manner  the  ulnar  side  of  the  hand 
can  be  made  more  smooth.  The  result  of  the  application  of  this 
principle  to  the  loss  of  the  two  central  fingers  is  shown  in  Figures 
183  and  184,  taken  many  years  after  the  operation.  This  was 
the  hand  of  a  hard  working  woman,  as  may  be  inferred  from  the 
strong  development  of  the  little  finger. 


CHAPTER    XV 
INFLAMMATIONS   OF  THE  ARM   AND   HAND 

EFFECTS  OF   HEAT   AND    COLD 

Burns. — The  hands  and  arms  are  especially  exposed  to  burns 
by  steam,  boiling  water,  flame,  electricity,  and  the  rays  of  the 
sun.  The  treatment  is  such  as  indicated  on  page  26.  If  the 
burned  surface  overlies  a  joint  it  is  desirable  to  keep  the  limb  in 
such  a  position  that  the  motion  of  such  joint  shall  not  be  inter- 
fered with  by  contraction  of  the  resulting  scar.  Hence  a  single 
splint  is  often  of  great  value  in  the  treatment  of  burns,  especially 
in  children.  If  the  burn  be  a  deep  one,  and  situated  over  a  joint, 
skin-grafts  should  be  applied  in  order  to  hasten  the  healing  and 
prevent  contraction  of  the  scar.  The  grafts  should  be  large  and 
should  comprise  a  considerable  part  of  the  thickness  of  the  skin. 
They  should  not  be  applied,  until  granulation  is  well  established. 
For  the  technic  see  Chapter  XX. 

Mangle  Injury.- — An  injury  peculiar  to  cities  is  produced 
by  a  laundry  machine  called  a  steam  mangle,  which  has  two  large 
steam  heated  rollers  through  which  clothing  is  passed  in  order  to 
dry  and  smooth  it.  If  the  girl  who  feeds  the  machine  has  the" 
misfortune  to  press  her  fingers  between  the  rollers,  the  hand  will 
be  drawn  forward  and  crushed  and  burned  at  the  same  time/  As 
a  result  of  this  accident  the  fingers  or  the  hand,  or  even  the  hand 
and  a  part  of  the  forearm,  will  be  ironed  out  flat  and  at  the  same 
time  severely  burned.  The  disfiguration  is,  of  course,  very  great, 
but  the  rule  holds  good,  none  the  less,  to  sacrifice  no  portion  of 
the  hand  or  finger  in  which  the  vitality  is  not  absolutely  destroyed. 
Skin-grafts  may  be  used  to  take  the  place  of  skin  which  has  been 
burned  or  torn  away.  Unfortunately,  function  is  destroyed  by 
this  accident  to  a  considerably  greater  distance  than  vitality,  so 
that,  even  though  the  fingers  or  a  considerable  part  of  them  be 

393 


394  INFLAMMATIONS   OF   THE   ARM   AND   HAND 

preserved,  the  hand   may  be  s r i tt'  and  nearly  useless.     But  even 
such  a  deformed  hand  is  far  better  than  an  artificial  substitute. 

Frost-bite. — Exposure  of  the  hands  to  cold  not  severe  enough 
to  actually  freeze  the  tissues  may  produce  a  condition  marked  by 
congestion  and  edema  and  analogous  to  chilblains  of  the  feet. 
There  will  be  symptoms  of  numbness,  alternating  with  burning 
pain.  Those  who  are  exposed  to  cold  should  protect  their  hands 
by  heavy  leathern  mittens,  and  should  stimulate  the  circulation  in 
the  fingers  by  dipping  the  hands  alternately  into  hot  and  cold 
water.  Similar  treatment  should  be  employed  daily  in  the  case  of 
hands  already  chilled,  and  following  this  the  skin  should  he  well 
rubbed  with  a  mildly  stimulating  ointment,  such  as  ichthyol. 

In  the  usual  frost-bite  of  the  fingers  the  action  of  the  cold  has 
been  sufficient  to  shut  off  all  circulation  until  some  of  the  tissues 
have  died.  When  the  hands  are  thawed  out  slowly,  by  rubbing, 
with' snow  or  rubbing  in  cold  water,  it  will  he  seen  that  no  blood 
circulates  in  parts  of  the  fingers.  Such  parts  remain  cold  and 
dark  when  the  rest  of  the  hand  becomes' warm.  The  color  passes; 
in  a  day  or  so,  from  a  dark  red  to  reddish  black  for  greenish  black,: 
and  it  is  evident  that  dry  gangrene  exists;  or,  if  there  is  plenty 
of  moisture,  blisters  may  form  under  the  skin. 

Treatment. — In  no  part  of  the  body  is  it  more  important  to 
preserve  as  much  of  the  tissue  as  possible.  Hence,  from  the  be- 
ginning, treatment  should  be  directed  toward  that  end.  After  the 
hands  have  been  slowly  brought  to  a  normal  temperature  they 
should  be  kept  warm  and  dry  by  wrapping  them  in  cotton,  so  as 
to  favor  the  efforts  of  the  circulation  to  keep  up  the  vitality.  This 
is  perhaps  best  accomplished  by  an  ointment  spread  upon  gauze, 
or  applied  directly  to  the  finger  and  covered  with  gauze,  outside 
of  which  a  thick  layer  of  non-absorbent  cotton  should  be  placed 
and  bandaged  without  much  pressure.  Such  an  ointment  often 
contains  tannic  acid  or  other  astringent  for  the  purpose  of  keep- 
ing dowm  the  edema  in  the  tissue  which  has  been  injured  but  not 
destroyed. 

Immediate  amputation  is  strictly  contraindicated.  It  often 
happens  that  the  apparent  gangrene  is  merely  superficial  and  that 
a  finger  may  live  and  remain  useful  an  inch  or  more  beyond  the 
line  of  demarcation  of  the  skin.  Even  if  such  ;i  happy  result  does 
not  follow  delay,  nothing  is  lost  by  conservative  treatment,  and 


GANGRENE   FROM   CARBOLIC   ACID   AND   OTHER   CAUSES      :j<J5 

the  patient  is  more  easily  reconciled  to  the  removal  of  a  portion 
of  a  finger  after  he  sees  that  all  attempts  to  preserve  it  have  failed. 
Compare  what  is  said  upon  this  in  the  following  paragraphs  on 
carbolic  gangrene. 

Gangrene  from  Carbolic  Acid  and  Other  External 
Causes.— Gangrene  of  the  finger  is  still  frequently  caused  by 
the  injudicious  use  of  carbolic  acid,  in  spite  of  all  that  has  been 
Written  on  this  subject.  Sometimes  the  responsibility  for  this 
rests  with  the  patient,  sometimes  he  acts  at  the  suggestion  of  a 
friend,  sometimes  a  druggist  is  at  fault,  and  sometimes,  sad  to 
tell,  a  doctor  applies  the  deadly  lotion. 

If  carbolic  acid  is  spilled  upon  the  skin  accidentally,  its  caus- 
tic action  may  be  prevented  by  promptly  bathing  the  part  with 


Fig.  185. — Partial  Gangrene  op  Finger  due  to  Carbolic  Acid.  There  was  loss 
of  the  true  skin  over  a  part  of  the  circumference  of  the  finger  only.  No  opera- 
tion was  performed.  Recovery  with  perfect  function  of  joints  and  tendons,  but 
with  a  permanent  scar.  Notice  the  swelling  of  the  living  tissue  adjoining  the 
gangrene. 

alcohol ;  but  in  most  of  the  cases  in  which  gangrene  is  produced 
a  solution  of  the  acid  is  employed,  and  the  destruction  of  the  skin, 
taking  place  slowly  and  often  painlessly,  is  not  recognized  until 
hours  have  elapsed.  It  is  then  too  late  for  relief  to  be  obtained  by 
bathing  with  alcohol. 

Gangrene  has  frequently  been  produced  by  the  application  of 
a  five  per  cent  solution  of  carbolic  acid  in  water,  and  in  some  in- 
stances by  the  use  of  a  watery  solution  of  only  one  per  cent.  Ex- 
periments show  that  a  similar  gangrene  may  follow  the  application 


396 


INFLAMMATIONS   OF  THE   ARM   AND    HAND 


of  five  per  cent  solutions  of  caustic  potash,  acetic  acid,  or  mineral 

acids. 

Carbolic  gangrene  is  dry  and  usually  painless.     The  affected 

part  is  at  first  dark  gray  or  brown,  and  as  the  tissues  dry  and 

shrivel  they  grow 
darker,  so  that  they 
become  almost  black 
(Fig.  185  and  Fig. 
1S6).  In  a  few  days 
a  line  of  demarcation 
is  established  between 
the  dead  and  living 
parts,  and  there  is 
some  swelling  of  the 
latter,  clue  to  absorp- 
tion of  septic  mate- 
rial along  the  line  of 
separation.  In  a  few 
cases  this  absorption 
may  lead  to  a  well 
marked  cellulitis 
with  the  formation 
of  pus  pockets  (Fig. 
187). 

The  termination 
of  the  gangrene  varies 
according  to  its  ex- 
tent. Thus  there  may 
be  loss  of  the  super- 
ficial skin  only,  with- 
out   permanent    scars, 


Fig.  180. — Carbolic  Gangrene  of  Distal  Half 
of  Finger,  Photographed  One  Week  After 
the  Application.  When  first  seen  the  gan- 
grene extended  beyond  the  web  of  the  finger. 
It  was  superficial  over  the  proximal  phalanx,  and 
the  sloughing  of  the  gangrenous  epidermis  ex- 
posed the  living  skin  beneath,  as  can  be  seen  in 
the  photograph.  Two  weeks'  delay  in  perform- 
ing the  amputation  enabled  the  surgeon  to  save 
the  proximal  phalanx,  and  to  cover  it  with  good 
flaps. 


or  a  part  of  the  cori- 
iim  may  be  destroyed,  or  the  deeper  tissues,  including  the 
bones.  The  line  of  demarcation  becomes  established,  granula- 
tions spring  from  the  proximal  side  of  the  line,  and  attempt 
to  close  the  wound.  The  bones  and  tendons  will  resist  disinte- 
gration longer  than  the  other  tissues,  but  they,  too,  must  yield 
in  time,  so  that  in  favorable  cases  a  spontaneous  cure  may 
take  place. 


GANGRENE   FROM  CARBOLIC  ACID  AND  OTHER  CAUSES      397 

Treatment. — The  treatment  of  carbolic  gangrene  is  at  first 
conservative.  As  in  frost-bite,  and  other,  forms  of  gangrene  from 
external  cause,  the  parts  should  be  kept  warm  and  dry,  and  ampu- 
tation should  be  postponed  until  the  line  of  demarcation  through 
the  true  skin  is  established.  Not  until  then  is  the  surgeon  able 
to  decide  positively  how  much  of  the  finger  can  be  preserved  with 
benefit.  This  delay  of  ten  days  or  two  weeks  also  increases  the 
vitality  in  the  partially  damaged  skin,  so  that  it  can  be  used  suc- 


Fig.  187. — Carbolic  Gangrene  of  the  Thumb,  Complicated  with  Cellulitis 
of  the  Thumb  and  Hand.  Sero-pus  escaped  through  the  incisions  naade  to 
relieve  tension. 


cessfully  for  a  flap  after  two  weeks,  when  the  same  flap  would 
certainly  not  have  been  viable  if  amputation  had  been  performed 
as  soon  as  the  gangrene  was  noticed. 

Sometimes  the  gangrene  is  complicated  with  cellulitis.    On  this 


398 


INFLAMMATIONS    OF   Till-:    AK.M    AND   HAND 


account,   while   waiting  for   a   distinct  line  of  demarcation,  the 
surgeon  should  Lnsped   the  affected   finger  daily.     If  tension  due 

to  swelling  interferes 
with  the  circulation, 
or  it'  abscesses  form, 
incisions  should  be 
made,  so  that  the  gan- 
grene may  not  extend 

i  Fig.  iss). 

For  the  treatment 

of  cellulitis  see  page 
402. 

Cellulitis  in  the 
hand  does  not  often 
lead  to  gangrene,  even 
when  it  develops  in 
diabetics  or  individ- 
uals otherwise  enfee- 
bled. Yet  it  may  do 
so.  Hence,  the  neces- 
sity for  free  incisions 
whenever  swelling 
within  the  restricting 
skin  of  the  finger 
threatens  to  cut  off 
the  circulation  from 
the  damaged  part.  Figure  192,  on  page  403,  shows  a  finger 
which  was  lost  by  neglect  of  this  precaution.  Such  gangrene 
is  moist. 

Whenever  a  cellulitis  which  is  well  drained  does  not  progress 
satisfactorily,  and  gangrene  is  threatened,  the  urine  should  be 
examined  for  sugar  and  albumin.  If  either  is  present  the 
treatment  should  be  prompt  and  radical,  as  delay  in  amputating 
a  finger  under  such  circumstances  may  lead  to  loss  of  an  arm 
later,  or  possibly  of  a  life.  Gangrene  due  to  diabetes  or  nephri- 
tis is  far  more  common  in  the  foot  than  in  the  hand.  (See 
Chapter  XVIII.) 


Fig.  188. — Same  Subject  as  Fig.  187.  Recovery 
with  no  loss  of  bone,  but  the  skin  was  so  tightly 
stretched  over  the  distal  phalanx  that  its  tip 
was  later  resected. 


ANATOMICAL  TUBERCLE  399 

INFLAMMATIONS 

Infection  in  Wounds. — Although  the  hand  is  exposed  to 

frequent  injuries,  large  and  small,  repair  usually  takes  place  with- 
out inflammation  sufficiently  marked  to  demand  surgical  treatment. 
Such  inflammation  as  does  occur  usually  follows  a  punctured 
wound,  or  a  wound  into  a  preformed  space,  such  as  a  joint  or 
bursa  or  synovial  sheath.  The  very  fact  that  the  wound  is  small 
favors  the  early  closure  of  its  mouth,  and  then,  as  the  introduced 
germs  multiply  in  it,  .they  find  it  easier  to  penetrate  the  deeper 
tissues  than  to  escape  to  the  surface. 

The  form  and  extent  of  the  inflammation  are  determined  by  the 
nature  of  the  wound,  by  the  nature  of  the  introduced  germs,  by 
the  health  of  the  individual,  etc.  T\Te  shall  consider  here  only 
the  forms  which  occur  with  frequency  in  the  upper  extremity. 
There  are  clinically  seven  such  forms,  the  lesions  in  four  being 
chiefly  local,  that  is  in  the  immediate  vicinity  of  the  wound ;  while 
in  three  they  are  chiefly  regional,  developing  at  a  distance  from  the 
wound  in  structures  wrhich  are  associated  with  the  wounded  part 
by  means  of  the  lymphatics. 

These  four  types  of  local  inflammation  are  anatomical  tubercle, 
acute  dermatitis,  cellulitis,  and  abscess;  and  the  regional  forms  arc 
lymphangitis,  lymphadenitis,  and  secondary  abscess.  These  forms 
of  inflammation  are  variously  combined,  but  one  or  the  other 
type  usually  predominates  in  any  given  case.  It  is  not  safe  to 
infer  from  the  form  taken  by  the  inflammation  that  it  is  due  to 
a  certain  germ,  for,  according  to  Welch,  "ell.  of  the  affections 
caused  by  one  species  of  the  pyogenic  cocci  may  be  caused  by  any 
of  the  others." 

Anatomical  Tubercle. — This  is  an  old  term  used  to  describe 
the  reaction  in  wOunds  in  the  dissecting-room,  which  were  common 
before  the  use  of  antiseptics.  The  term  is  still  of  use  to  describe 
a  form  of  inflammation  without  suppuration  limited  to  the  imme- 
diate vicinity  of  the  wound,  lasting  many  days,  and  terminating 
in  resolution,  without  or  with  a  local  necrosis  of  the  skin  (Fig. 
189).  This  wound,  as  all  others,  may  be  the  starting-point  for  a 
more  wide-spread  inflammation.  Anthrax  (Fig.  Y9,  p.  132),  syph- 
ilis (Fig.  215,  p.  436),  and  tuberculosis  all  form  similar  lesions, 
so  that  a  bacteriological  examination  should  be  made,  if  possible. 


400 


INFLAMMATIONS   OF  TUK   ARM   AND   HAND 


a   malignant   character  of  the   infecting 


Anatomical  tubercle  should  be  treated  by  we1  dressings.     If 

organism   is   proved  or 
suspected,  the  tubercle 

should  lie  excised. 

Dermatitis ;  Ery- 
sipelas. —  1  )ermatitis 
produced  by  germ  inva- 
sion is  marked  by  ede- 
ma, redness,  tenderness, 
and  pain,  and  a  constant 
daily  extension  of  the 
involved  area.  Erysip- 
elas is  the  typical  der- 
matitis of  this  charac- 
ter. It  spreads  rapidly, 
often  as  much  as  an 
inch  a  day,  more  rapid- 
ly in  the  direction  of 
the  lymph  current  than 
against  it.  It  may  also 
he  known  by  the  gener- 
al symptoms  of  an  ini- 
tial chill  and  a  high 
fever,  but  as  a  rule  the 
symptoms  are  less  se- 
vere when  the  erysipe- 
las occurs  on  an  extremity  than  when  the  face  is  involved.  ^Toist, 
antiseptic  dressings,  applied  and  allowed  to  evaporate,  give  the  pa- 
tient some  relief  from  the  pain,  but  they  do  not  seem  to  have  much 
effect  upon  the  spread  of  the  dermatitis.  Fortunately,  the  inflam- 
mation tends  to  become  less  and  less  active  the  further  it  spreads, 
and  so  gradually  dies  out,  and  the  patient  recovers.  In  a  minority 
of  eases  the  inflammation  extends  to  the  deeper  tissues,  producing 
cellulitis,  lymphangitis,  and  abscesses,  which  may  prove  fatal. 

A  good  application  is  formalin,  one  per  cent  solution,  or  a  solu- 
tion of  carbolic  acid  one  part  in  sixty  parts  of  alcohol  and  sixty 
parts  of  water.  This  is  weak  enough  not  to  produce  gangrene, 
and  the  anesthetic  action  of  the  carbolic  acid  is  advantageous.  (See 
also  erysipelas  of  the  face,  p.  35.) 


Fig.  189. — Anatomical  Tubercle,  Duration  One 
Week.  'Die  patient  was  a  butcher,  aged  twen- 
ty-two years. 


ERYSIPELOID 


401 


Erysipeloid. — An  equally  typical  infective  dermatitis  occurs 
on  the  hands  of  those  engaged  in  handling  moat.  It  is  often  spoken 
of  as  an  erysipeloid  to  distinguish  it  from  the  more  active  erysip- 
elas. It  does  not  usually  produce  an  initial  chill,  and  is  accom- 
panied by  only  a  slight  rise  in  temperature.  There  is  redness  and 
edema  of  the  skin,  with  a  distinct  edge  to  the  affected  area,  which 
spreads  outward  in  all  directions  very  slowly,  averaging  one-quarter 
of  an  inch  a  day  (Fig.  190).  There  is  considerable  local  pain, 
sufficient  at  times  to  disturb  sleep.  After  a  few  days  the  infection 
dies  out  in  some  parts  of  its  growing  edge,  while  still  advancing 


Fig.  190. — Erysipeloid  Dermatitis  developing  in  a  Wound  of  Hand  of  Seven 
Days'  Duration.  Erysipeloid  dermatitis  noticed  for  three  days.  Patient  a 
butcher  aged  twenty-one  years. 


in  others,  so  that  it  terminates  in  a  number  of  separated  and  some- 
what faded  red  spots,  which  gradually  disappear  in  two  or  three 
weeks.  Treatment  consists  in  applications  to  relieve  the  pain. 
Ichthyol  ointment  has  some  advantages. 


402 


INFLAMMATIONS   OF   THE    ARM    .VXD   HAND 


Cellulitis. — Cellulitis  is  ;i  diffuse  .-welling  of  the  skin  and 
deeper  sofi  tissues,  due  to  infection.  The  lines  of  the  .skin  are 
obliterated,  the  outline  of  the  pari  is  changed,  its  functions  are 
limited,  and  it  is  held  in  a  position  of  relaxation  so  that  the  painful 
pressure  upon  inflamed  nerves  may  be  as  little  as  possible  (Fig. 
191). 

Cellulitis  is  so  often  an  accompaniment  of  an  abscess  that  in 
every  ease. of  cellulitis  search  should  be  made  for  suppuration.  It 
may  be  concealed  under  the  dried  crusl  of  an  abrasion.  A  small 
collection  of  pus  beneath  sound  skin  gives  greater  resistance  to  the 
palpating  finger  than  the  remainder  of  the  inflamed  area,  and  it 
is  also  much  more  tender  to  the  touch.  If  the  quantity  of  pus  is 
larger  and  near  the  surface,  fluctuation  can  be  obtained  by  making 

sudden  slight  impres- 
sions with  one  finger, 
while  another  rests 
quietly  upon  the  sus- 
pected surface.  Pus 
also  gives  a  whitish  or 
yellowish  tint  to  the 
skin  over  it  as  com- 
pared with  the  sur- 
rounding skin.  This 
is  a  confirming  sign, 
which  sometimes  ap- 
pears early  enough  to 
be  of  value  to  the  sur- 
geon, and  which  con- 
vinces the  patient  as 
no  other  sign  can,  that 
the  abscess  is  "  ripe 
enough  to  cut." 

Treatment. — Cel- 
lulitis of  the  band  or 
arm  should  be  treated 
by  the  application  of 
gauze  wet  with  an 
evaporating  lotion,  and  the  part  should  be  kept  at  rest  and  mod- 
erately elevated  by  means  of  a  sling.     Evaporation  should  not  be 


Fig.  191. — Cellulitis  of  Finger  with  Abscess  op 
Six  Days'  Duration.  Patient  a  man  aged 
thirty-one  years. 


CELLULITIS 


403 


prevented  by  oiled  silk  or  any  impervious  material.  The  effect 
of  the  fluid  is  greater  if  it  contains  some  alcohol.  It  may  be 
applied  either  hot  or  cold.     The  use  of  antiseptics  in  the  fluid  is 


Fig.   192. — Gangrene  of  Finger   Following  Cellulitis,   and  Apparently  due 
to  Unrelieved  Tension.     The  details  are  stated  in  the  text. 


very  common,  but  probably  has  no  effect  whatever  if  the  skin 
is  not  broken.  The  fluid  chosen  should  not  produce  permanent 
stains  on  the  clothing;  for  this  reason  lead  and  opium  wash,  and 
aqueous  solutions  of  ichthyol  are  not  to  be  recommended. 

If  pus  is  present  it  should  be  evacuated  through  a  suitable  in- 
cision, as  mentioned  below.  The  best  signs  of  pus  are  local  ten- 
derness on  pressure,  and  increased  local  tension.  Even  if  there  be 
no  visible  collection  of  pus,  marked  increase  of  tension  and  pain 
are  sometimes  sufficient  indications  for  incision.  Thus,  the  gan- 
grene of  the  finger  shown  in  Figure  192  might  have  been  avoided 
by  an  early  incision.  The  history  of  this  case  is  so  instructive  that 
it  is  worth  giving  in  detail. 

A  healthy  man,  aged  thirty-two,  scratched  the  back  of  his 
fourth  digit  with  the  wire  on  a  bale  of  hay.  For  five  days  he 
28 


404  INFLAMMATIONS   <>F  THE   ARM  AND   HAND 

noticed  no  especial  change  in  the  finger.  Then  it  began  to  swell, 
and  he  presented  himself  for  treatment  on  the  ninth  day.  There 
was  moderate  cellulitis  of  the  whole  finger,  with  puffiness  at  both 
phalangeal  joints,  but  no  especial  tenderness  at  any  point.  A  wet 
dressing  of  aluminum  acetate  was  applied.  The  next  day  the  finger 
was  in  about  the  same  condition.  The  patient  had  slept  well,  had 
a  good  appetite,  and  little  if  any  fever.  The  wet  dressing  was 
reapplied.  The  next  day  the  condition  was  about  the  same.  The 
question  of  incision  was  discussed  and  decided  against  for  the 
reason  that  the  process  was  not  extending,  there  was  no  lymphatic 
affection  either  in  the  vessels  or  glands,  the  general  health  of  the 
patient  was  undisturbed,  and  no  local  point  of  tenderness  or  fluc- 
tuation could  be  made  out.  The  following  day  was  Sunday,  and 
the  patient  was  not  seen.  On  Monday  the  epithelium,  anteriorly 
and  posteriorly,  was  lifted  by  watery  blebs  and  the  underlying 
skin  of  the  finger  was  discolored,  although  there  was  no  sharp 
line  of  demarcation.  There  were  still  no  constitutional  symp- 
toms, and,  no  cause  for  gangrene  being  evident,  the  hand  was 
again  dressed  and  put  on  a  splint.  The  next  day  there  was 
fluctuation  in  the  posterior  tendon  sheath,  and  the  demarcation 
between  living  and  dead  tissue  was  more  apparent.  The  photo- 
graph, of  which  Figure  192  is  a  reproduction,  was  taken;  the  pus 
was  evacuated  through  a  wide  posterior  incision,  and  the  inflam- 
matory process  rapidly  subsided.  !No  carbolic  acid  had  been  used ; 
the  infection,  as  shown  by  its  course  and  by  cultures  made  from  the 
pus,  was  not  especially  virulent,  and  one  is  forced  to  the  conclusion 
that  the  gangrene  of  the  finger  was  the  result  of  excessive  tension 
and  that  an  early  longitudinal  incision  made  anywhere  through  the 
skin  of  the  finger,  by  relieving  this  tension,  might  have  avoided 
this  gangrene. 

Boil ;  Furuncle. — Suppuration  in  the  arm  and  hand  is  some- 
what controlled  by  existing  structures  so  that  it  presents  several 
well  marked  forms.  The  pus  may  be  in  the  skin  in  the  form  of 
a  pimple  or  a  boil  (Fig.  193).  These  lesions  may  have  the  same 
characteristics  as  similar  lesions  in  other  parts  of  the  body,  but  it 
is  worth  noting  that  the  epidermis  of  the  palmar  surface  of  the 
fingers  and  hand  is  so  thick  that  pus  may  collect  in  it,  raising  the 
superficial  portion  like  a  blister.  This  is  insensitive  and  can  be 
cut  away  with  forceps  and  scissors,  exposing  the  deeper  layer  of 


boil  405 

epidermis.  This  should  be  sponged  and  inspected,  for  it  often  con 
tains  a  sinus  leading  to  a  second  abscess  underneath  the  skin,  the 
so-called  "  collar  button  "  abscess.  For  the  opening  of  the  deeper 
part  of  such  an  abscess,  local  anesthesia  is  required.  Great  care 
should  be  taken  not  to  carry  the  incision  beyond  the  abscess  cavity 
so  that  operation  may  not  spread  the  infection  beyond  its  existing 


Fig.   193. — Boil  of  Wrist  with  Secondary  Pimples.     Original  infection  from  a 
corpse;  secondary  infection  from  the  discharge  from  the  first  boil. 

limits.      (See  also  p.  411.)     A  small  wick  of  gutta-percha  tissue 
makes  an  excellent  drain. 

When  the  pus  is  situated  in  a  finger  deeper  than  the  true  skin, 
the  development  of  the  abscess  will  be  determined  to  a  considerable 
extent  by  the  peculiar  anatomical  relations  which  exist  in  the  fin- 
gers, and  especially  in  the  finger-tip.  Figure  194  shows  in  a 
diagrammatic  way  how  pus  may  form  in  four  different  spaces,  and 
the  symptoms  will  be  more  or  less  different  in  each  case.  These 
four  spaces  are:  A,  the  space  between  the  dorsal  skin  and  the 
matrix ;  B,  the  space  between  the  matrix  and  the  formed  nail ; 

C,  the  space  between  the  formed  nail  and  the  underlying  skin; 
28 


Hill  INFLAMMATIONS   OF  THE    \UM    AND   HAND 


Fig.  194.-  Section  of  Terminal  Segment  op  Finger.  An  abscess  may  form 
between  the  dorsal  skin  and  the  matrix  of  the  nail  :il  .1  ;  <>r  between  the  matrix 
and  the  formed  nail  at  1>\  or  between  the  nail  and  t  lie  underlying  skin  at  C;  or 
between  the  skin  and  the  fronl  of  the  phalanx,  as  shown  in  D. 

and  /},  the  space  between  the  skin  and  the  front  or  side  of  the 

phalanx.  These  are  not  pre- 
formed spaces,  but  with  the  de- 
velopment of  pus  in  the  .tissues 
they  become  abscess  cavities. 

An  abscess  of  the  type  D 
usually  following  a  prick  with 
a  pin  or  splinter,  situated  in 
the  distal  segment  of  the  thumb 
or  finger,  may  "  point "  at  the 
very  tip  of  the  finger.  If  not 
properly  relieved  it  may  extend 
deeper,  causing  necrosis  of  the 
tip  of  the  last  phalanx,  or  it 
may  extend  upward  into  the 
hand  or  into  the  flexor  tendon 
sheath.  Fortunately  these  com- 
plications are  relatively  late  in 
occurrence,  so  that  if  the  abscess 
is  drained  within  a  few  clays  of 
its  origin  they  are  usually  avoid- 
ed. The  flexor  tendons  do  not 
extend  further  than  the  base  of 
the  distal  phalanx;  consequently 
suppuration  which  is  limited  to 


Fig.  195.— Abscess  Tip  of  Thumb  of 
Thirteen  Hays'  Duration,  with 
Spontaneous  Rupture;  Type  D, 
Fig.  194.  Note  that  the  swelling 
does  not  pass  the  interphalangeal 
joint. 


PARONYCHIA  407 

the  distal  segment  of  the  digit  cannot  involve  the  tendon  sheath; 
yet  this  type  of  suppuration  is  often  wrongly  spoken  of  as  a 
"felon,"  a  convenient  term  for  purulent  thecitis  or  suppura- 
tion in  a  tendon  sheath.  Fig.  195  shows  a  thumb  with  an 
abscess  of  type  D  of  thirteen  days'  duration,  which  ruptured 
spontaneously. 

Abscesses  of  types  C  and  D  should  be  opened  by  a  transverse 
incision  at  the  tip  of  the  digit,  following  one  of  the  natural  lines 
in  the  skin.  This  incision  gives  good  drainage,  and  leaves  far 
less  deformity  than  a  longitudinal  incision.  The  nail  should  not 
be  removed. 

Paronychia. — Paronychia,  or  "  run-around,"  is  suppuration 
about  the  root  of  a  nail.  In  order  to  understand  its  development 
and  the  treatment  which  will  afford  relief,  one  should  know  how 
a  nail  grows.  The  epithelium  of  the  back  of  the  finger  is  folded 
in  upon  itself  and  thickened.  This  double  layer  of  actively  multi- 
.plying  cells  reaches  nearly  to  the  terminal  joint,  and  is  called 
the  matrix  of  the  nail,  Figure  194,  C  and  D.  The  lower  part 
of  the  matrix  is  thicker  than  the  upper  and  forms  the  greater 
part  of  the  nail.  The  distal  edge  of  the  underlying  part  of  the 
matrix  forms  the  whitish  semilunar  line  visible  in  most  finger- 
nails. A  nail  which  is  thick  and  strong,  like  the  thumb-nail,  has 
a  more  extended  matrix  than  the  more  delicate  nails  on  the  ulnar 
side  of  the  hand. 

If  a  splinter  or  a  pin  passes  between  the  nail  and  its  matrix, 
above  or  below,  the  tissues  are  damaged,  blood  and  serum  col- 
lect in  the  wound,  and  an  abscess  may  result.  Such  an  abscess 
may  result  from  infection  entering  through  a  break  in  the  skin 
at  the  side  of  the  nail — a  hang-nail.  The  pus  will  at  first  be 
confined  between  the  half  formed  nail  and  its  matrix,  and  it  will 
spread  more  easily  transversely  than  in  any  other  direction;  but 
before  much  pus  accumulates  in  the  situation  B,  Figure  194,  it 
will  also  travel  beyond  the  matrix  and  enter  the  space  C.  The  re- 
verse also  happens,  but  the  space  C  is  much  larger  and  an  abscess 
starting  beneath  the  nail  in  C  is  often  some  distance  from  the 
proximal  edge  of  the  nail.  The  spontaneous  rupture  of  a  parony- 
chia is  usually  posteriorly  between  the  nail  and  the  reflected  skin 
(Fig.  196).  The  drainage  thus  obtained  is  not  sufficient  to  effect 
a  cure,  but  usually  prevents  the  suppuration  from  extending  to 


408  INFLAMMATIONS   OF  THE   ARM   AND   HAND 

the  front  of  the  linger,  or  upward  into  the  hand,  though  these 
complications  do  occur. 

Treatment. — This   naturally   varies   according   to   the   situ- 
ation of  the  pus.     If  the  pus  is  beneath  the  formed  nail,  a  suffi- 


•"■ 

r         o 

/ 

K      iJ 

M 

1  n 

Fig.  196. — Acute  Paronychia  of  Three  Weeks'  Duration,  with  Spontaneous 
Rupture  of  Abscess.  Pus  in  spaces  marked  A  and  B,  Fig.  194.  Patient  a 
woman  aged  twenty-one  years. 

cient  part  of  the  latter  should  be  cut  away  to  give  free  exit.  Such 
a  condition  often  follows  the  passage  of  a  splinter  beneath  the 
nail,  even  though  it  does  not  extend  as  far  as  the  edge  of  the 
matrix. 

If  the  pus  is  in  space  B  and  has  not  yet  extended  to  space  A 
a  transverse  incision  should  be  made  through  the  reflected  skin 
the  whole  width  of  the  nail.  In  doing  this  the  scalpel  should  be 
kept  flat  upon  the  nail  and  close  to  it,  so  that  the  incision  does 
not  appear  on  the  surface  of  the  finger  at  all.  In  many  cases  it 
is  no  incision  at  all,  simply  a  bloodless  separation  of  the  nail  from 
the  posterior  part  of  the  matrix. 

If  the  pus  is  in  the  space  B,  reaching  toward  C,  a  transverse 
incision  should  be  made  clear  across  the  nail  at  the  semilunar 
line,  and  the  proximal  portion  of  the  nail  removed.     It  will  be 


PARONYCHIA  409 

found  adherent  only  at  its  lateral  margins.  If  the  distal  portion 
of  the  nail  is  still  attached  to  the  tender  skin  beneath  it,  it  may- 
be left  as  a  protector.  In  many  cases  it  will  have  been  lifted  up 
by  the  pus.  The  upper  and  lower  portions  of  the  matrix  should 
be  kept  apart  for  two  or.  three  days  by  a  folded  piece  of  rubber 
tissue,  and  a  wet  dressing  applied. 

A  longitudinal  incision  is  less  satisfactory,  since  it  does  not 
properly  drain  the  pus  cavity.  Multiple  longitudinal  incisions 
have  been  advised  by  some,  but  they  are  unnecessarily  mutilating, 
and  require  constant  care,  lest  they  close  prematurely  and  fail  to 
drain.     Moreover  any  longitudinal  incision  which  is  made  deep 


Fig.  197. — Acute  Paronychia  Ten  Days  After  Removal  of  Old  Nail,  and  One 
Month  After  the  Beginning  of  the  Suppuration.     Same  subject  as  Fig.  196. 

enough  to  pass  through  the  whole  matrix  is  likely  to  produce  a 
permanent  ridge  in  the  nail  or  a  split  nail.  Drainage  carried 
out  as  indicated  above  will  invariably  be  followed  by  a  perfect- 
nail. 

Figure  197  shows  the  finger  ten  days  after  removal  of  the 
nail  to  secure  proper  drainage.  All  suppuration  has  subsided,  and 
the  uninjured  new  nail  is  already  showing. 


410 


INFLAMMATIONS   OF   THE   ARM   AND   HAND 


If  drainage  is  secured  as  already  indicated  by  removal  of  the 

proximal  portion  of  the  nail,  while  the  older  portion  is  left  to 
protect  the  finger,  the  new  nail  by  ir>  growth  must  push  the  old 
nail  off  from  the  finger.     Its  thin  edge  may  be  crumpled  up  by  so 

doing,  and  this  may  cause  the  patient 
some  pain.  The  removal  of  the  rem- 
nant of  the  old  nail  will  give  the  pa- 
tienl  relief,  and  make  it  easier  for  the 
new  nail  to  grow  out  smooth  and 
straight.  The  tenderness  of  the  fin- 
der resulting  from  removal  of  the  old 
nail  quickly  subsides. 

Chronic  Paronychia. — Portions  of 
formed  nail,  which  are  partly  loosened 
and  partly  attached,  may  act  as  foreign 
bodies  and  keep  up  suppuration.  This 
gives  a  chronic  form  of  paronychia 
(Fig.  198).  Treatment  consists  in  the 
removal  of  every  bit  of  formed  nail 
and  the  application  of  a  wet  dressing 
for  a  few  days.  The  two  layers  of  the 
matrix  should  he  kept  apart  by  the  in- 
terposition of  rubber  tissue,  or  a  probe 
may  he  passed  between  them  every  two 
nv  three  days  until  the  new  nail  ap- 
pears. This  method  of  treatment  will 
insure  a  nail  without  deformity  unless 
the  matrix   has   been   previously   dam- 


Fig.  198. — Chronic  Parony- 
chia, Four  Months.  Note 
that  the  edges  of  the  old 
nail  interfere  with  the  new, 
leading  to  local  recurrences 
of  suppuration.  Patient  a 
woman  aged  twenty -two 
years. 


aged. 


A  patient  will  usually  wish  to  know 
how  long  it  will  he  before  the  appear- 
ance of  the  finger  is  restored.  It  is 
safe  to  say  that  it  will  be  three  months  before  the  new  nail  grows 
out  to  the  tip  of  the  finger,  and  at  least  another  two  months 
before  the  irregular  part  of  the  new  nail  has  grown  off  and  has 
been  cut  away. 

There  is  still  a  fifth  type  of  suppuration  in  the  last  segment 
of  the  finger.  This  type  of  suppuration  often  starts  in  a  torn 
"  hang-nail,"  and  is  situated  generally  at  the  side  of  the  finger. 


SUPPURATIVE   TIIEOITLS 


41 L 


It  may  be  drained  through  an  incision  made  by  keeping  the  knife 
flat  on  the  nail,  or  else  by  a  longitudinal  incision  made  through  the 
skin.  The  latter  is  parallel  to  the  natural  lines  of  the  skin  at  the 
side  of  the  finger. 

Suppuration  in  the  proximal  or  middle  segment  of  a  finger 
may  be  simply  subcutaneous,  or  in  a  tendon  sheath,  or  in  a  joint. 
It  is  of  the  greatest  importance  to  recognize  the  fact  that  many 
abscesses  of  the  finger  are  simply  in  the  subcutaneous  fat,  arid 
do  not  involve  the  special  structures  of  the  digit.  In  opening  such 
an  abscess  the  skin  only  should  be  divided,  great  care  being  taken 
not  to  spread  the  suppuration  by  the  careless  incision  of  a  hitherto 
not  infected  tendon  sheath  or  joint.  It  the  situation  of  the  pus 
warrants  it,  it  is  best  to  make  the  incision  a  little  to  one  side  of 
the  median  line. 

Suppurative  Thecitis.  —Suppuration  in  a  tendon  sheath  is 
called  purulent  thecitis,  or  felon,  or  whitlow.     The  infective  agent, 


Fig.  199. — Abscess  in  the  Tendon'  Sheath  of  the  Thumb  from  a  Spi.ixter,  of 
Two  Weeks'  Duration.  Compare  the  shape  of  this  thumb  with  that  shown 
in  Fig.  195  on  page  406.  Fifth  digit  contracted  thirty-five  years  from  infection. 
Patient  a  man  aged  forty  years. 


412  INFLAMMATIONS   OF  THE   ARM    AND  HAND 

which  in  the  serious  cases  al  Least,  is  usually  a  streptococcus,  is 
generally  carried  by  a  pin,  needle,  or  sliver  into  the  tendon  sheath 
of  the  flexor  side  of  the  linger  or  thumb  (  Fig.  L99  ).  Suppuration 
does  not  immediately  distend  the  whole  length  of  the  sheath,  so 
thai  a  timely  incision  may  prevenl  its  spreading  so  far  as  the  palm 
of  the  hand.  Its  extension  from  the  tendon  sheath  of  one  digit  to 
that  of  another  is  rarely  seen,  although  mentioned  as  an  anatom- 
ical possibility  in  the  ease  of  the  thumb  and  little  finger. 

The  symptoms  of  suppurative  thecitis  may  not  be  sufficiently 
distincl  to  enable  one  to  say  positively  whether  the  pus  is  inside 
of  the  tendon  sheath  or  merely  subcutaneous.  This  distinction  is 
the  less  important,  since  in  either  case  it  is  necessary  to  divide 
the  skin  for  drainage,  and  when  this  has  been  done  it  will  be 
evident   whether  the  sheath   is  or  is  not  distended  with  pus. 

In  both  cases  there  are  edema  of  the  finger,  great  tenderness, 
and  possibly  tense  fluctuation.  Motions  of  the  joints  are  inhibited 
by  the  tenderness,  so  that  the  inability  of  the  patient  to  flex  the 
finger  is  not  of  much  assistance  in  a  differential  diagnosis.  Pain 
caused  by  contraction  of  the  flexor  muscles  when  the  finger  is  so 
held  that  no  motion  of  the  bones  is  possible,  is  significant  of  sup- 
puration within  the  sheath.  If  there  is  pus  in  a  joint,  pressure 
on  the  tip  of  the  finger  will  cause  pain.  If  the  pus  is  inside 
or  outside  of  a  tendon-sheath,  sudi  pressure  will  not  be  especially 
painful. 

Treatment. — Pus  in  a  tendon  sheath,  like  pus  everywhere 
else,  demands  evacuation.  In  general,  incisions  for  this  purpose 
should  be  longitudinal,  in  order  to  avoid  unnecessary  injury  of 
vessels  and  nerves ;  and  while  the  incision  should  be  deep  enough 
and  long  enough  to  afford  free  drainage,  in  no  case  should  it  be 
made  deeper  than  the  pus.  The  old  rule  to  cut  every  felon  to  the 
bone  is  a  barbarity  which  has  no  place  in  modern  surgery. 

The  close  relations  of  the  tendon  sheaths  to  many  important 
structures  in  the  hand  makes  it  desirable  that  some  more  exact 
rides  should  be  given  for  their  drainage.  In  every  case  of  sup- 
puration in  the  hand,  unless  it  is  evident  that  the  case  is  one  of 
the  simple  types  already  described  in  which  the  pus  cavity  is  situ- 
ated within  or  just  beneath  the  skin,  a  general  anesthetic  should 
be  given.  Furthermore  the  parts  should  be  rendered  bloodless  by 
elevation  of  the  arm  and  application  of  a  tourniquet  around  the 


SUPPURATIVE   THECITIS  413 

upper  arm.  The  best  form  consists  of  five  or  six  turns  of  an 
elastic  rubber  bandage.  In  no  case  should  the  bandage  be  wound 
spirally  around  the  whole  arm  from  the  hand  upward,  lest  the 
suppuration  be  spread  in  this  way. 

The  first  incision  should  be  made  through  the  point  of  infec- 
tion. Even  if  a  previous  incision  has  been  made  at  that  point, 
it  will  often  be  found  to  be  insufficient  to  afford  free  drainage. 
If  the  case  is  seen  at  an  early  stage,  this  digital  incision  may 
suffice. 

In  making  the  incision  one  should  divide  one  tissue  plane  after 
another  for  a  distance  of  about  an  inch.  As  each  plane  is  divided, 
it  should  be  fully  retracted,  so  that  the  operator  may  see  exactly 
what  he  is  doing. 

It  is  important  to  remember  that  in  some  cases  of  deep  suppu- 
ration of  the  finger,  as  well  as  of  the  hand,  the  pus  lies  outside 
of  the  tendon  sheath.  One  should  never  hunt  for  pus  with  a  probe, 
in  this  portion  of  the  body  at  least,  as  it  may  spread  the  infection. 
When  an  abscess  has  been  opened,  its  extent  may  be  determined  by 
a  probe,  provided  the  latter  is  not  passed  into  the  tendon  sheath. 

If  incision  is  made  in  the  finger  or  the  thumb,  it  should  be 
made  either  in  the  median  line  or  slightly  to  one  side  of  it.  It 
should  be  carried  deeper,  step  by  step,  with  the  flaps  retracted,  in 
a  good  light,  until  the  pus  is  evacuated.  If  the  tendon  sheath  is 
exposed  and  is  not  distended  with  fluid,  it  should  in  no  case  be 
incised.  If  it  is  distended  with  fluid,  the  character  of  the  same 
may  be  ascertained  by  aspiration  with  a  hypodermic  syringe.  If 
purulent  or  seropurulent,  the  tendon  sheath  should  be  drained  by 
an  incision  from  half  an  inch  to  an  inch  long. 

If  the  whole  tendon  sheath  is  distended  with  pus,  it  will  be 
necessary  to  drain  also  its  upper  end.  Incision  for  this  purpose 
in  case  of  the  index,  middle,  and  ring  fingers  should  be  made  in 
the  palm  of  the  hand  directly  over  the  tendon  involved.  An  in- 
cision about  one  inch  long,  with  its  center  opposite  the  metacarpo- 
phalangeal joint  will  usually  suffice  (Fig.  200,  D).  The  tendon 
sheath  should  never  be  laid  open  from  end  to  end,  as  this  pro- 
cedure is  almost  certain  to  cause  sloughing  of  the  tendon. 

One  word  of  caution  in  regard  to  palmar  suppuration:  The 
tendon  sheath  of  course  lies  beneath  the  palmar  fascia.  This  lim- 
its the  swelling  of  the  palm.     On  the  back  of  the  hand  there  is  no 


414 


INFLAMMATIONS   OF   THE   ARM   AND   HANI) 


such  strong  fibrous  tissue  to  limit  swelling,  and  it  sometimes  hap- 
pens thai  the  back  of  the  hand  will  be  more  swollen  than  the 
front,  although  the  suppuration  may  lie  wholly  confined  to  the 
space  hoi  ween  the  metacarpal  hones  and  the  palmar  fascia. 

One  should  not  be  misled  l>y  this  swelling  into  making  a  pos- 
terior incision,  for  at  this  stage  of  the  process  posterior  incision 
is  useless.  Such  was  the  series  of  events  in  the  case  shown  in 
Figures  200  and  201.  The  patient,  a  nurse,  noticed  a  soreness 
in  the  end  of  the  lefl   index-finger.     There  was  no  history  of  in- 


Fig.  200. — Suppuration-  in  the  Index- Finger  Extending  into  the  Palm  (Puru- 
lent Thecitis).  A,  The  point  of  infection  and  the  original  incision,  probably 
insufficient  in  depth;  D,  incision  at  the  upper  end  of  the  tendon  sheath  which 
stopped  the  infective  process;  E,  an  incision  into  the  abscess  cavity  outside  of 
the  tendon  sheath.  There  are  small  drains  in  incisions  D  and  E.  Patient  a 
woman  aged  twenty-five  years. 


jury,  and  no  abrasion  in  the  skin  could  be  discovered.  An  hour 
later  the  finger  began  to  ache  and  throb.  Two  hours  after  that 
there  was  a  chill  and  a  temperature  of  102,  and  the  pain  had 
extended  into  the  hand  and  arm.  Five  hours  after  the  first 
symptom  the  finger  was  tense,  swollen,  and  extremely  sensitive, 


SUPPURATIVE  THKCITIS 


415 


and  there  was  a  small  yellow  spot  near  the  tip  on  the  palmar  sur- 
face., It  was  cocainized  and  incised  by  a  physician,  but  no  pus 
was  found  (Fig.  200,  A).  A  wet  dressing  was  applied.  The 
following  day  the  swelling  had  extended   to  the  hand   and   arm, 


Fig.  201. — Same  Subject  as  Fig.  200.  Posterior  view.  Incisions  B  and  C,  which 
failed  to  reach  the  cavity  of  the  abscess  on  account  of  their  wrong  situation. 
The  drain  at  C  extends  through  the  hand  from  D. 


and  the  general  symptoms  were  more  severe.  On  the  second  day 
after  the  first  symptoms  another  physician  chloroformed  the  pa- 
tient, and  made  a  lateral  incision  in  the  finger  and  a  posterior 
incision  in  the  hand,  being  misled  by  the  great  amount  of  swell- 
ing in  these  two  places.  Cloudy  serum,  but  no  pus  was  found 
(Incisions  B  and  C,  Fig.  201).  Two  days  later,  as  the  swelling 
in  the  hand  and  arm  continued,  I  saw  the  patient,  and  under  ether 
made  a  palmar  incision  into  an  abscess  cavity  (Incision  D,  Fig. 
200),  and  also  a  second  incision  at  the  outer  limit  of  the  abscess 
cavity  (Fig.  200,  E).  There  seems  no  reason  to  doubt  that  the 
palmar  incision  would  have  terminated  the  suppuration  if  it  had 
been  made  on  the  second  day,  just  as  readily  as  it  did  when  it  was 


410 


INFLAMMATIONS    OF   THE   ARM    AND    HAND 


made  on  the  fourth  day.     A  temperature  chart  is  appended,  Fig- 
ure 202. 

The  photographs,  which  were  taken  some  days  later,  do  not 
show  the  amount  of  swelling  thai  existed  at  the  time  of  incision, 


104 

103 
102 

-*/\ 

= 

101 
100 



— fi 

"     C 

~A/£ 

99 
98 

o 

<5f 

}     — . 

97 

PULSE. 

| 

RESP 

| 

1 

DAY  OF 

DISEASt 

^ 

c* 

CO 

<5t- 

^ 

VO 

t^ 

CO 

cr> 

Fig.  202. — Temperature  Chart  of  the  Patient  Whose  Hand  is  Shown  in 

Fig.  200. 

and    are   introduced   to   show   the   correct   and   incorrect  sites   of 
incision.     The  suppuration  at  the  tip  of  the  finger  involved  the 


Fig.  203. — Same  Subject  as  Fig.  200.     Ultimate  result  three  months  later. 

hone,  a  part  of  which  disintegrated  and  came  away  in  granular 
form.  The  ultimate  result  is  shown  in  Figure  203.  The  patient 
obtained  a  movable  finger. 


SUPPURATIVE  THECITIS  417 

In  case  the  suppuration  involves  the  tendon  sheath  of  the 
thumb  or  little  finger,  the  situation  is  much  more  complicated, 
since  these  tendon  sheaths  usually  extend  into  the   wrist. 

Three  incisions  may  therefore  be  necessary  to  afford  sufficient 
drainage:  First,  the  digital  incision  at  the  point  of  infection,  usu- 
ally near  the  tip  of  the  thumb  or  little  finger;  second,  the  incision 
in  the  palm;  and  third,  the  incision  in  the  wrist. 

In  the  case  of  the  thumb,  the  palmar  incision  should  be  made 
along  the  inner  border  of  the  outer  head  of  the  flexor  brevis  pol- 
licis.  This  incision  is  almost  in  line  with  the  inner  surface  of 
the  thumb  when  the  first  phalanx  is  fully  extended  on  the  meta- 
carpal bone.  It  should  not  be  carried  further  upward  than  the 
second  carpometacarpal  joint,  for  fear  of  dividing  branches  of 
the  median  nerve  going  to  the  short  muscles  of  the  thumb. 

The  incision  in  the  wrist  may  be  made  either  to  the  inner  or 
outer  side  of  the  tendon  of  the  flexor  carpi  radialis,  a  landmark 
which  is  easily  recognized.  It  should  extend  from  the  lower  trans- 
verse crease  of  the  wrist  an  inch  or  inch  and  a  half  upward.  One 
comes  more  directly  upon  the  tendon  of  the  thumb  by  making  the 
incision  to  the  inner  side  of  the  flexor  carpi  radialis,  but  drain- 
age in  this  situation  sometimes  inflames  the  median  nerve.  It  is 
therefore  probably  better  to  make  the  incision  outside  of  the  ten- 
don of  the  flexor  carpi  radialis,  and  if  the  radial  artery  is  exposed 
to  contact  with  the  drain,  it  should  be  ligated  in  two  places  and 
divided.  Otherwise  its  wall  may  become  eroded,  and  fatal  hem- 
orrhage result. 

When  the  infection  starts  in  the  little  finger,  the  palmar  in- 
cision should  be  placed  between  the  digital  branches  of  the  median 
and  ulnar  nerves.  In  order  to  avoid  these  nerves,  it  should  be 
made  directly  over  the  fourth  metacarpal  bone,  beginning  a  little 
above  the  head  of  the  bone  and  extending  upward  to  the  annular 
ligament.  The  superficial  palmar  arch  must  be  ligated  and 
divided. 

The  incision  in  the  wrist  must  be  so  situated  as  to  expose  the 
flexor  sublimis  and  flexor  profundus  tendons,  as  the  pus  sur- 
rounds or  separates  these  when  it  extends  above  the  annular  liga- 
ment. This  large  bundle  of  tendons  is  easily  felt  in  the  normal 
wrist.  The  incision  should  be  along  the  inner  border  of  the 
bundle.     If  the  tendons  cannot  be  felt,  a  linear  incision  should  be 


Il.s      INFLAMMATIONS  OF  THE  ARM  AND  HAND 

made  from  the  lowesl  transverse  crease  of  the  wrist  upward  for 
an  inch  and  a  half,  and  in  a  line  one-half  inch  to  the  outer  side 
of  the  tendon  of  the  flexor  carpi  ulnaris.  This  tendon,  it  will  he 
remembered,  terminates  in  the  pisiform  bone.  If  even  these  land- 
marks ;irc  obscured,  the  line  selected  for  incision  should  be  placed 
one-third  of  the  distance  from  the  ulnar  to  the  radial  side  of  the 
wrist.  The  sublimis  tendons  arc  quickly  exposed.  Pus  may  lie 
superficial  to  them  or  between  them  and  the  profundus  tendons,  or 
between  the  profundus  tendons  and  the  pronator  quadratus.  If 
the  pus  is  in  the  Last  named  space,  it  may  he  well  to  make  ;i  second 
incision  along  the  ulnar  border  of  the  wrist,  so  as  to  obtain  drain- 
age behind  the  tendon  of  the  flexor  carpi  ulnaris.  The  only  two 
structures  which  one  need  fear  in  making  these  incisions  are  the 
idnai'  nerve  and  the  ulnar  artery.  The  nerve  lies  close;  to  the 
outer  (radial)  side  of  the  flexor  carpi  ulnaris  tendon  and  the 
artery  just  outside  of  the  nerve,  next  to  the  snhlimis  tendons. 
The  artery  may  be  divided  and  ligated,  if  necessary. 

AlS  stated  above,  the  tendon  sheath  should  never  be  opened 
if  the  pus  lies  only  outside  it.  If  the  sheath  has  to  be  opened  on 
account  of  pus  within  it,  no  probe  or  director  should  be  pushed 
upward  along  the  sheath,  lest  it  carry  the  infection  further  than 
it  has  already  gone.  The  operator  should  rely  on  the  external 
appearance  of  the  finger,  on  the  feeling  of  tension,  and  the  pain 
caused  by  pressure  to  guide  him  in  making  his  incision.  When 
the  pus  cavity  has  been  opened,  and  the  edges  of  the  wound  are 
retracted,  the  eye  is  the  safest  guide  to  the  extent  of  the  cavity ; 
but  there  is  not  the  same  objection  to  the  use  of  a  probe  in  abscess 
cavities  vhich  extend  away  from  the  tendon  sheath.  Such  cav- 
ities, especially  when  situated  near  the  base  of  the  finger  and  out- 
side of  the  tendon  sheath,  frequently  extend  from  front  to  back, 
or  from  back  to  front  of  the  finger,  and  so  need  to  be  opened  on 
both  sides  in  order  to  be  properly  drained. 

The  abscess  cavity  should  be  washed  and  sponged  clean,  but 
not  curetted — a  most  cruel  procedure  and  absolutely  useless.  The 
whole  extent  of  the  wound  superficial  to  the  tendon  sheath  should 
be  lightly  filled  with  gauze  to  prevent  its  surfaces  from  adhering. 
A  gauze  dressing  should  be  applied  and  kept  constantly  moist  with 
a  mild  antiseptic  or  water.  Some  doctors  seem  to  have  a  passion 
for  stuffing  a  wound  full  of  iodoform  gauze  and  covering  it  with 


SUPPURATIVE  THECITIS  419 

a  dry  dressing.  In  the  case  of  a  clean  wound  this  does  very  little 
harm;  in  a  suppurating  wound,  unless  the  outflow  of  pus  is  very 
free,  the  plug  may  suffice  to  keep  most  of  the  pus  within  the 
wound,  while  a  little  escapes  and  dries  in  the  dressing.  This  may 
seal  up  the  wound  and  literally  reproduce  the  abscess,  one  side 
of  which  will  then  he  formed  by  the  gauze  and  inspissated  pus. 
Pus  will  then  reaccumulate  under  pressure,  and  the  usual  signs 
of  an  abscess — swelling,  heat,  pain,  etc. — will  reappear.  It  is 
needless  to  say  that  such  treatment  retards  the  healing  of  the 
wound,  even  if  no  more  serious  result  follows.  If  the  gauze  is 
placed  loosely  in  the  wound,  and  the  dressing  is  kept  constantly 
moist,  the  pus  will  soak  into  the  dressing  as  fast  as  it  forms.  Its 
accumulation  under  pressure  is  impossible,  and  the  absorption  of 
further  infectious  material  is  at  least  not  favored. 

If  drainage  is  required  in  the  deeper  portion  of  the  wound, 
gutta-percha  tissue  presents  many  advantages.  Being  more  flexible 
than  rubber-tubing,  it  conforms  to  the  shape  of  the  wound,  and 
therefore  exerts  a  minimum  of  injurious  pressure.  Unlike  gauze, 
it  never  adheres  to  a  wound,  and  as  it  does  not  soak  up  the  dis- 
charge, it  cannot  by  evaporation  become  dry  and  prematurely  seal 
the  wound.  If  it  is  desired  to  keep  a  larger  opening,  the  gutta- 
percha tissue  may  be  rolled  loosely  around  a  wick  of  gauze,  making 
a  flabby  cigarette  drain  (Fig.  306). 

The  part  should  be  kept  at  rest.  If  the  inflammation  is  slight, 
it  is  sufficient  to  place  the  hand  in  a  sling.  If  the  inflammation 
is  more  severe,  a  splint  should  also  be  employed. 

The  hand  should  be  dressed  once  or  twice  a  day.  A  good  plan 
is  to  soak  it  in  a  hot,  weak,  antiseptic  solution  for  half  an  hour, 
before  or  after  removing  the  dressing.  This  stimulates  the  circu- 
lation, and  greatly  favors  the  exit  of  pus.  If  irrigation  is  em- 
ployed, the  fluid  used  should  be  mild  in  character,  and  injected 
with  great  gentleness.  One  should  never  use  a  strong  solution  of 
peroxid  of  hydrogen,  as  the  rapidly  forming  bubbles  of  gas  dis- 
tend the  sinuses,  causing  the  patient  pain,  and  possibly  spread- 
ing the  infection.  One  part  of  peroxid  to  six  of  water  is  suffi- 
ciently strong  for  such  use.  An  abundance  of  a  weak  fluid  is  a 
far  better  cleanser  than  a  little  strong  antiseptic. 

In  most  cases  nothing  is  gained  by  an  early  removal  of  the 
gauze  which  has  been  placed  in  the  wound.     Unless  there  are 


420 


INFLAMMATIONS   OF  THE   ARM   AND   HAND 


-iuu-  of  insufficient  drainage,  i.e.,  continued  or  increasing  swell- 
ing, tenderness  and  beat,  ii  is  better  to  leave  the  gauze  packing 
for  three  or  four  days  until  ii  lnn-cns.  As  granulations  form, 
the  dressing  need  nol  be  changed  so  frequently,  and  in  a  week 
or  more  ;i  balsam  of  Peru  gauze  may  be  inserted,  and  a  dry 
dressing  employed.  When  the  wound  has  become  superficial,  mas- 
sage and  passive  motions  should  be  added  to  the  treatment,  so  as 
to  maintain  .  the  mobility  of 
joints  and  tendons. 


Fig.  204.  —  Suppuration  in  Tendon 
Sheath  Four  Weeks.  Drainage 
sufficient  to  reduce  the  swelling,  but 
not  to  effect  a  cure. 


Fig.  205.  —  Back  of  Same  Finger. 
Note  the  absence  of  characteristic 
swelling. 


Sometimes  the  patient  does  not  apply  for  treatment  until  the 
abscess  in  the  tendon  sheath  has  ruptured  externally,  or  has  been 
evacuated  through  a  minute  incision.  This  relieves  the  acute 
swelling  (Figs.  204  and  205),  and  changes  the  shape  of  the  finger, 
as  is  easily  seen  by  comparison  with  Figure  191,  page  402,  but 
leaves  an  imperfectly  drained  sinus.  Proper  drainage  may  then 
be  obtained  by  a  longer  incision  or  a  second  incision  opposite  the 
proximal  phalanx. 


SUPPURATIVE   THECITLS 


421 


Complications. — Suppuration  in  a  tendon  sheath  if  not  too 
violent  or  too  long  continued  may  subside  and  leave  a  movable 
tendon.  If  more 
severe,  the  tendon 
is  adherent,  but 
will  usually  become 
movable  in  time. 
If  the  process  is 
still  more  severe, 
the  tendon  sloughs, 
the  wound  heals  by 
granulation,  and 
the  scar  ultimate- 
ly contracts,  giving 
a  useless  finger, 
whose  joints  are 
movable,  but  which 
cannot  be  flexed, 
flexor  ten- 
gone,  and 
be  extend- 
account  of 
the  scar.  This 
was  the  condition 
of  the  little  finger 
in  the  hand  shown 
in  Figure  199,  on 
page  -'11.  If  such  a  finger  is  in  the  middle  of  the  palm  its  flexed 
phalanges  should  be  amputated  (Fig.  206).  If  a  finger  remains 
rigidly  extended,  it  is  almost  as  much  in  the  way. 

The  results  of  an  old  infection  of  the  hand,  which  involved 
all  the  extensor  tendons,  is  shown  in  Figure  207.  The  ulcer  is 
recent. 

A  virulent  infection  of  a  tendon  sheath  may  lead  to  necrosis 
of  bone,  or  even  gangrene  of  the  whole  finger,  but  before  it  does 
so  it  usually  extends  to  the  synovial  sheaths  of  the  hand  and 
wrist,  or  to  the  joints,  and  it  may  form  an  abscess  in  the  forearm 
or  axilla,  or  go  on  to  general  septicemia  and  death. 

If  the  infection  extends  above  the  wrist,  it  may  form  an  ab- 


as the 
don  is 
cannot 
ed    on 


Fig.  206. — Cicatricial  Contraction  of  Finger  Fol- 
lowing Suppuration  in  Tendon  Sheath  Twenty- 
five  Years  Previous.  Joint  movable,  but  tendon 
"•one. 


422 


INFLAMMATIONS  OF  THE   ARM   AND   HAND 


scess  in  the  forearm,  beneath  the  bellies  of  the  flexor  sublimus 
muscle.     Such  an  abscess  should  be  opened  along-  the  ulnar  border 


Fig.    207. — Loss   of   Extensor   Tendons   from   Suppuration,    and   Contraction 
of  Scar  of  Many  Years  Previous.     The  ulcer  is  recent. 

of  the  forearm,  between  the  flexor  carpi  ulnaris  and  the  flexor 
sublimus  digitorum  muscle.     In  this  way  all  risk  of  injuring  the 

median  nerve  is 
avoided.  The  ul- 
nar nerve  is  pro- 
tected by  the  flexor 
carpi  ulnaris  mus- 
cle. Should  the  ul- 
nar artery  be  in- 
jured, it  may  be 
ligated  and  divided 
without  harm  to 
the  patient. 

ISTo  matter  how 
extensive  the  sup-  ■ 
puration,  the  same 
principles  of  treat- 
ment are  applica- 
ble,   viz.,    free    in- 


Fig.  208. — Suppuration  in  Joint  Following  Pene 
tration  by  a  splinter  slx  weeks  previously. 


cision,  drainage  fa- 
cilitated by  a  wet  dressing  or  a  constant  bath,  and  absolute  rest 
to  the  part.    These  principles  faithfully  observed  will  often  fully 


SUPPURATIVE   SYNOVITIS 


423 


restore  the  function,  even  though  suppuration  has  extended  into 
the  forearm. 

Suppurative  Synovitis;  Suppurative  Arthritis. — In- 
fection may  reach  a  joint  and  set  up  suppuration  in  the  synovial 
sac  which  lines  it,  or  in  the  ends  of  the  bones  themselves.  This 
accident  is  usually  due  to  the  direct  entrance  of  some  sharp  instru- 
ment into  the  joint  itself. 
For  example,  a  man  with 
clenched  fist  strikes  an- 
other a  blow  in  the  mouth. 
The  edge  of  one  of  the 
incisor  teeth  may  easily 
break  through  the  skin 
and  the  capsule  of  the 
metacarpophalangeal 
joint  as  they  are  tightly 
stretched  over  the  head  of 
the  bone.  The  wound  it- 
self appears  trivial,  but 
in  the  course  of  a  day  or 
two  the  joint  swells  and 
becomes  very  painful,  a 
little  mucopurulent  fluid 
finds  its  way  out  through 
the  wound,  and  may  be 
recognized  by  its  tenac- 
ity if  the  finger  which 
touches  it  is  slowly  drawn 
away.  This  is  an  absolute 
sign  that  fluid  has  come 
from  the  cavity  of  a  joint 
or  synovial  sheath  or  a  bur- 
sa ;  in  other  words,  that  it  contains  mucin.  Pressure  on  the  end  of 
the  injured  finger,  tending  to  crowd  the  bones  together,  causes  pain. 

The  shape  of  the  swollen  finger  also  indicates  that  the  in- 
flammation is  located  in  a  joint;  for  its  maximum  transverse 
diameter  coincides  with  the  plane  of  the  affected  joint,  the  whole 
finger  being  fusiform  (Fig.  208).  Compare  the  shape  of  the 
fingers  shown  in  Figure  191,  page  402,  and  Figure  204,  page  420, 


Fig.  209. — -Suppurative  Arthritis  and  Loss 
of  Metacarpal  Following  Wound  of 
Joint  Made  by  Teeth  One  Year  Pre- 
vious. 


424 


INFLAMMATION'S   OF  THE   ARM   AND   HAND 


Suppuration  in  a  joint,  if  prolonged,  leads  to  destruction  of 
the  cartilage,  and  later  i  I'  a  portion  of  one  or  both  bones  which 
make  np  the  joint.     It'  only  one  bone  is  destroyed,  there  mav  still 


Fir:.   210. — Radiograph  of  a   Hand    in   which    There   was   Extensive  Loss  of 
Bone   Following  Suppurative  Arthritis. 


be  considerable  motion  in  the  joint,  so  great  is  the  power  of  the 
body  to  maintain  its  functions  under  adverse  circumstances.     In 


SUPPURATIVE   SYNOVITIS  425 

Figure  209  is  shown  an  extreme  case  of  this  character,  in  which 
the  whole  metacarpal  bone  was  lost  from  suppuration  following 
a  tooth-wound  on  the  Lack  of  the  metacarpophalangeal  joint. 
The  finger  had  a  considerable  range  of  motion.  Figure  210  is  a 
radiograph  of  a  similar  case  in  which  a  part  of  the  metacarpal 
bone  was  preserved.  In  the  usual  case  the  destruction  of  carti- 
lage produces  a  rough  grating  when  the  bones  are  slipped  upon 
each  other ;  but  if  free  drainage  is  instituted  at  this  stage  the  case 
goes  on  to  recovery  without  loss  of  bone.  Convalescence  is  slow, 
however,  and  the  function  of  the  joint  may  never  be  fully  regained. 
If  treatment  is  commenced  before  erosion  of  the  cartilaginous 
ends  of  the  bones,  two  or  three  weeks'  treatment  should  result 
in  complete  healing  of  the  wound,  and  restoration  of  function 
should  ultimately  be  complete. 

Treatment. — The  treatment  of  suppurative  synovitis  con- 
sists in  an  incision  into  the  joint,  irrigation  of  the  joint  cavity 
with  peroxid  of  hydrogen  and  water,  one  part  to  six  or  eight,  a 
moist  gauze  dressing,  with  or  without  a  drain  which  reaches 
through  the  capsule  of  the  joint,  and  a  splint  to  keep  the  bones 
absolutely  at  rest.  If  the  wound  is  a  posterior  one,  the  incision 
should  also  be  made  posteriorly.  If  the  wound  is  an  anterior 
one,  the  joint  may  perhaps  be  drained  more  satisfactorily  from 
the  posterior  side ;  or  anterior  and  posterior  drainage  may  be 
indicated.  In  a  few  days  when  the  acute  suppuration  has  sub- 
sided, the  daily  discharge  will  consist  of  a  few  drops  of  sero- 
mueopurulent  fluid.  If  a  drain  has  been  kept  in  the  joint  cavity, 
it  should  now  be  removed.  The  gauze  dressing  should  be  light, 
not  more  than  six  or  eight  or  twelve  thicknesses,  so  that  the  splint 
may  hold  the  finger  firmly.  A  sheet  of  thin  tin,  cut  from  a 
cracker-box  and  molded  accurately  to  the  finger  and  hand,  an- 
swers admirably  for  this  purpose  (Fig.  211).  A  pattern  should 
first  be  cut  out  of  paper.  The  base  of  the  splint  should  reach 
nearly  to  the  carpus,  and  should  extend  for  an  inch  on  either  side 
of  the  metacarpal  bone.  The  remainder  of  the  splint  should  be 
broad  enough  to  form  a  gutter  half  encircling  the  finger.  The 
sharp  edges  of  the  splint  should  be  slightly  bent  away  from  the 
hand  to  avoid  pressure. 

Sometimes,  on  account  of  pain,  the  finger  cannot  at  once  be 
extended.     The  splint  should  then  be  bent  to  fit  the  position  of 


426  INFLAMMATIONS   OF   THE   ARM    AND   HAND 

the  finger,  and  at  each  daily  dressing  a  little  more  extension  can 
thus  be  obtained. 

Treatment  of  this  character  to  be  successful  must  extend  over 
several  weeks.     In  the  beginning  the  dressing  should  be  changed 


Fig.  211. — Tin  Splint  Cut  from  Cracker-box  with  Bandage  Scissors,  for  Use 
in  Case  of  Suppuration  of  the  Metacarpophalangeal  Joint  of  the  Second 
Digit.  At  the  left  of  the  illustration  are  two  paper  patterns.  The  tin  splint  was 
cut  from  the  pattern  next  to  it.  The  other  shows  the  shape  of  a  splint  for  the 
third  or  fourth  metacarpophalangeal  joint. 

every  day,  and  later  on  three  times  a  week.  The  ultimate  result 
in  many  instances  will  be  a  movable  joint,  although  one  cannot 
promise  such  a  favorable  outcome.  However,  most  patients  prefer 
even  a  stiff  joint  to  resection  of  a  joint  or  amputation  of  the 
finger,  which  are  the  alternatives  of  choice. 

When  the  sinus  has  quite  healed,  the  patient  should  still  wear 
his  splint  and  keep  the  finger  at  rest  for  a  couple  of  weeks,  treat- 
ing the  finger  with  a  daily  bath  and  rub,  but  not  attempting  to 
bend  it  until  the  swelling  and  soreness  have  disappeared.  Undue 
eagerness  on  the  part  of  the  surgeon  or  patient  to  prevent  stiffness 
of  the  finger  by  early  motion  will  probably  result  in  a  renewed 
secretion  of  mucopurulent  fluid  into  the  joint  cavity,  which  will  in 
turn  require  another  incision  and  a  new  period  of  treatment. 


SUPPURATIVE   OLECRANON    BURSITIS  427 

If  the  ends  of  the  bones  are  dead,  so  that  they  grate  roughly 
upon  one  another,  the  casting  off  of  the  dead  tissue  may  still 
safely  be  left  to  nature  if  free  drainage  is  provided.  This  is  a 
tedious  process,  and  the  financial  condition  of  the  patient  may 
make  necessary  the  resection  of  the  ends  of  the  bones  or  the  am- 
putation of  the  finger.  The  latter  operation  usually  gives  a 
shorter  period  of  recovery. 

The  description  of  suppuration  in  one  of  the  joints  of  the 
fingers  and  the  treatment  therewith  outlined  is  applicable  to  sup- 
puration in  the  larger  joints  of  the  wrist  and  arm;  but  the  con- 
stitutional effects  of  these  larger  lesions  are  so  great  that  the 
patient  who  suffers  with  them  has  passed  from  the  field  of  "  minor 
surgery." 

Suppurative  Olecranon  Bursitis. — A  rather  common  form 
of  abscess  in  the  arm  starts  in  the  olecranon  bursa.     The  wound 


Fig.  212. — Suppurative  Olecranon  Bursitis.      The  characteristic  swelling  of  the 
distended  bursa  is  somewhat  masked  by  the  cellulitis  around  it. 

may  be  insignificant.  The  germs  multiply  rapidly  in  the  bursa,  as 
they  do  in  all  preformed  serous  cavities.  If  the  bursa  is  intact,  so 
that  the  seromucopurulent  contents  cannot  escape,  palpation  will 
at  once  reveal  a  distinct  rounded  tense  swelling.  In  most  cases  the 
fluid  which  accumulates  in  the  bursa  escapes  through  the  wound, 


42S 


INFLAMMATIONS   OF   THE    ARM    AND    HAND 


and  this  prevents  distention  of  the  bursa,  while  the  edema  of  the 
adjacent  soft  parts  obscures  its  outline.  This  renders  a  diagnosis 
more  difficult.  Sometimes  suppuration  starting  in  the  bursa  breaks 
into  the  tissues  outside  its  wall,  and  then  the  usual  signs  of  a 
subcutaneous  abscess  are  added  (  Fig.  212). 

Treatment  consists  in  exposure  of  the  abscess  cavity  by  a  longi- 
tudinal incision.  Tbe  bursa  should  be  removed  or  allowed  to 
granulate  from  the  bottom,  as  otherwise  relapse  is  likely  to  occur. 
If  there  is  an  extensive  abscess,  ii  is  often  of  advantage  to  drain 
on  both  sides  of  the  arm.  Through  and  through  drainage  by  means 
of  gauze  or  rubber  tubing  may  then  be  employed,  but  only  for  a 
few  days.  After  that  the  drains  should  be  inserted  from  both  sides, 
but  should  not  touch  in  the  middle,  so  that  repair  of  the  deeper 
portion  may  be  favored.  It  is  easy  to  keep  up  a  sinus  by  leaving 
a  drain  through  a  limb. 

Lymphangitis. —  It  was  slated  on  page  399  that  inflamma- 
tory lesions  may  develop  in  related  structures  at  a  distance  from 
the  origin  of  an  infection.  Tbese  lesions  are  conveniently  spoken 
of  as   "  regional  "   in   relation   to  tbe  original  lesion.      Tbey  are 


Fig.  213. — Infected  Wound  of  Finger  with  Abscess  Developing  in  the  Course 
of  the  Lymphatic   Vessel.     The  arrows  are  directed  to  these  points. 

lymphangitis  and  lymphadenitis.     Either  may  lead  to  the  forma- 
tion of  an  abscess. 

Lymphangitis  is  produced  by  the  extension  of  infection  along 
the  lymph  vessels  which  drain  the  site  of  an  infected  wound. 
Usually  the  wound  is  insignificant;  sometimes  it  is  found  with 
difficulty.      Tbe  inflammation  of  the  lymph  vessels  causes  them 


LYMPHADENITIS  429 

to  appear  as  slightly  indurated  red  streaks.  They  are  usually  only 
slightly  tender  and  painful.  More  than  one  vessel  is  involved 
in  most  cases. 

Treatment  consists  in  the  cleansing,  and  drainage,  if  necessary, 
of  the  original  wound.  When  this  has  been  accomplished  the  lym- 
phangitis quickly  subsides,  sometimes  in  a  day  or  two.  The  portion 
of  the  arm  which  is  inflamed  is  often  enveloped  in  a  wet  dressing. 
This  may  be  either  cold  or  hot.  The  dressing  makes  the  arm  feel 
comfortable,  and  by  maintaining  an  even  temperature  it  probably 
facilitates  recovery,  but  its  curative  action  must  be  very  slight. 

Only  rarely  does  an  abscess  form  in  the  course  of  the  inflamed 
lymphatics  (Fig.  213). 

Lymphadenitis. — The  regional  lymph  glands  are  very  fre- 
quently involved  in  connection  with  infected  wounds  of  the  fingers 
and  hand.  In  many  instances  it  is  evident  that  the  bacteria  pass 
through  the  lymphatic  vessels  without  visibly  affecting  them,  and 
produce  a  reaction  in  the  lymphatic  glands.  The  glands  at  the 
elbow  are  not  often  involved ;  those  in  the  axilla  are  usually  the 
ones  affected,  whether  the  wound  is  on  the  front  or  the  back  of 
the  hand.  In  many  cases  the  glands  are  palpably  enlarged  and 
tender,  but  if  the  original  wound  is  properly  treated,  suppuration 
in  the  glands  does  not  take  place ;  but  even  in  favorable  cases  they 
do  not  so  quickly  resume  their  normal  condition  as  do  the  lym- 
phatic vessels.  One  or  two  weeks  are  often  necessary  before  the 
tenderness  and  swelling  disappear.  In  other  cases  the  swelling 
of  the  glands  continues  or  increases  until  abscesses  are  formed  in 
them,  which  in  the  course  of  time  may  break  through  the  capsules 
and  form  a  single  large  abscess.  Infection  from  the  hand  affects 
the  deeper  glands  of  the  axilla,  so  that  the  latter  may  swell  to  a 
considerable  extent  before  the  skin  shows  any  change. 

If  the  infection  starts  in  the  hair-follicles  of  the  axilla,  and 
an  abscess  is  formed  in  the  subcutaneous  fat  or  in  the  superficial 
glands,  the  parts  present  quite  a  different  appearance  (Fig.  214). 
This  is  a  very  common  trouble,  and  one  which  is  annoying  rather 
than  serious.  The  skin  is  invariably  reddened,  and  shows  one  or 
more  pustules,  or  perhaps  also  sinuses,  if  the  abscess  has  already 
ruptured.  The  whole  inflamed  mass  can  be  moved  upon  the  deep 
axillary  fascia.  The  process  is  correctly  termed  a  superficial  axil- 
lary abscess. 


430 


INFLAMMATIONS    OF   THE    ARM    AND    HAND 


Treatment. — Local  anesthesia  is  sufficient  for  the  treatment 
of  a  superficial  axillary  abscess.  The  hair  should  be  cropped  with 
scissors,  the  skin  washed  and  cocainized.  The  abscess  should  then 
be  opened  by   a   transverse   incision  near  its  lowest   portion,   an 


Fig.  214. — Superficial  Axillary  Abscess  from  Infection  About  Hairs;  Twelve 
Days.  Pus  is  seen  dropping  from  a  spontaneous  rupture.  Patient  a  man  aged 
thirty-nine  years. 

incision,  in  other  words,  parallel  to  the  seam  joining  a  sleeve  to 
a  coat.  Fragments  of  glands  should  be  curetted  or  cut  away,  and 
if  more  than  one  abscess  cavity  exists,  they  should  all  be  made  to 
drain  freely  into  the  wound.  The  edges  of  the  wound  should  be 
kept  apart  by  gauze  for  some  days,  until  granulation  is  well  estab- 
lished in  the  deeper  parts  of  the  wound. 

The  treatment  of  suppurating  deep  glands  of  the  axilla  is  a 
more  serious  undertaking,  and  is  best  carried  out  when  a  general 
anesthetic  has  been  given.     The  skin  of  the  axilla  should  be  shaved 


ECZEMA  431 

and  cleansed  and  a  longitudinal  incision  made ;  an  incision,  in 
other  words,  parallel  to  the  edge  of  the  greater  pectoral  muscle. 
If  the  glands  are  freely  movable  in  the  surrounding  areolar  tissue 
their  removal  is  easy;  it  may  be  very  difficult  if  exudation  has 
matted  the  various  planes  of  tissue  together.  Under  such  cir- 
cumstances the  surgeon  may  think  it  best  simply  to  open  the  various 
abscesses,  drain  them,  and  wait  for  the  wounds  to  close  by  granu- 
lation. He  usually  has  to  wait  some  weeks,  as  the  tissue  of  the 
gland  is  so  spongelike  that  it  affords  a  splendid  opportunity  for  the 
continued  propagation  of  bacteria,  while  the  circulation  in  this 
spongy  tissue  is  so  good  that  the  bacteria  do  not  generally  cause 
its  necrosis  after  the  pressure  has  been  relieved  by  the  incision  of 
the  gland  capsule.  Therefore,  it  is  a  good  rule  to  remove  a  sup- 
purating gland  wherever  this  can  be  done  easily.  The  next  best 
thing  to  the  complete  removal  of  the  gland  is  to  scoop  it  out  of 
its  capsule  piecemeal  by  means  of  a  curette.  If  the  glands  are 
removed  entire,  temporary  drainage  with  rubber  tissue  will  suffice 
and  the  greater  part  of  the  incision  may  be  sutured.  If  the 
glands  are  merely  incised,  or  incised  and  curetted,  or  if  the  ab- 
scess at  the  time  of  operation  has  already  extended  beyond  the 
capsule  of  the  gland,  gauze  drainage  through  an  unsutured  in- 
cision should  be  maintained  for  some  days  until  granulation  takes 
place. 

The  treatment  outlined  for  the  deep  suppurating  glands  is  the 
same  as  that  employed  for  tuberculosis  of  the  axillary  glands.  In 
the  latter  case  there  is,  of  course,  an  additional  reason  for  the 
complete  removal  of  the  glands  in  that  the  seeds  of  disease  which 
they  contain  may  spread  to  other  glands  or  other  organs. 

Eczema.  — The  hand  and  forearm  are  favorite  seats  of  eczema, 
which  occurs  in  all  its  forms — erythematous,  papular,  vesicular, 
and  pustular.  When  of  a  chronic  character,  scales  and  crusts  and 
fissures  are  well  shown,  particularly  upon  the  palm.  Besides  what- 
ever form  of  "  debility  "  may  be  the  predisposing  cause  of  the 
eczema,  if  the  lesions  are  located  upon  the  hand  or  arm,  there  is 
almost  always  a  well  marked  local  cause  such  as  exposure  to  heat 
or  cold,  contact  with  strong  chemicals,  including  laundry  soaps  and 
washing  powders,  irritating  sand,  etc.  The  history  will  generally 
indicate  the  diagnosis,  which  will  be  confirmed  by  the  presence  of 
the  four  cardinal  symptoms — erythema,  serous  exudation,  infiltra- 


432  INFLAMMATIONS   OF   THE   ARM    AND   HAND 

tion  of  the  underlying  skin,  and  itching.     Eczema  must  be  differ- 
entiated from  the  following  diseases: 

Urticaria  occurs  in  wheals  scattered  indiscriminately  over  vari- 
ous surfaces  of  the  body. 

Erysipelas  gives  a  continuous  blush,  which  spreads  constantly 
from  the  edge.  This  and  its  constitutional  symptoms  sufficiently 
distinguish  it  from  eczema. 

Dermatitis  from  poison  ivy  closely  resembles  acnte  eczema. 
Its  distinguishing  characteristics  are  a  history  of  exposure  to  the 
plant,  the  acute  spread  of  the  lesions,  and  their  transference  from 
one  part  of  the  body  to  another  by  contact,  as  from  the  hands  to 
the  face,  neck,  or  genitals. 

Treatment. — Applications  useful  in  the  treatment  of  eczema 
have  been  mentioned  on  page  58.  If  the  best  results  are  to  be 
obtained,  the  irritating  causes  must,  of  course,  be  done  away 
with. 

Sometimes  a  syphilitic  eczema  of  the  finger,  especially  of  the 
forefinger  or  thumb,  will  persist  long  after  all  other  signs  of  the 
disease  have  disappeared.  The  constitutional  treatment  should 
be  continued  under  such  circumstances,  even  though  the  patient 
may  have  taken  medicine  regularly  for  the  usual  period  of  two 
years  or  more.  In  addition,  local  applications,  such  as  mercurial 
ointment,  Lassar's  paste,  or  strong  preparations  of  salicylic  acid 
should  be  applied  during  the  night,  in  order  to  cause  the  old  skin 
to  scale  off  and  give  place  to  a  newer,  healthier  growth. 

Ulcer  from  Vaccination. — In  normal  vaccination  the  pus- 
tules dry  up  and  the  resulting  scab  remains  in  place  until  the 
repair  of  the  skin  is  complete.  If  germs  of  various  sorts  are 
allowed  to  enter  the  lesion,  at  the  time  of  vaccination,  or  afterward 
by  a  premature  removal  of  the  scab,  the  inflammation  and  loss  of 
tissue  may  be  extreme.  It  is  no  unusual  thing  to  find  an  ulcer 
on  the  arm  or  leg  of  a  child  an  inch  in  diameter  and  one-third  of 
an  inch  deep.  Such  an  nicer  is  usually  very  slow  in  healing,  and 
should  be  stimulated  with  nitrate  of  silver.  The  ulcer  may  be 
painted  with  a  ten  per  cent  solution  of  nitrate  of  silver,  or  gauze 
wet  with  a  four  per  cent  solution  may  be  kept  over  the  ulcer. 
This  dressing  should  be  moistened  four  times  a  day  with  water 
and  changed  every  day  until  granulation  is  well  established.  (Com- 
pare the  treatment  of  ulcers  of  the  leg,  Chapter  XVIII.) 


GONORRHEAL  ARTHRITIS  433 

Articular  Rheumatism. — The  less  acute  inflammations  of 
the  upper  extremity  are  for  the  most  purl,  located  in  the  joints. 
A  complete  study  of  joint  affections  is  manifestly  impossible  in  a 
work  of  this  character,  hut  it  is  worth  while  to  consider  the  sur- 
gical aspects  of  articular  rheumatism,  gonorrheal  arthritis,  arthritis 
deformans,  gout,  syphilis,  and  tuberculosis. 

The  onset  of  articular  rheumatism  is  sudden,  with  fever  and  its 
accompanying  symptoms.  One  or  more  joints  are  diffusely  swollen, 
and  very  tender  and  painful.  Different  joints  may  be  involved  at 
the  same  time,  or  one  after  the  oilier.  The  affected  joint  contains 
little  fluid.  The  administration  of  salicylates  internally  seems  in 
some  cases  to  hasten  the  restoration  to  normal  of  the  affected 
joints.  In  other  cases  it  seems  to  have  no  effect  in  this  way.  Pain, 
redness,  and  extreme  tenderness  usually  disappear  in  a  few  days. 
Some  swelling,  and  limitation  of  motion  by  tenderness  and  adhe- 
sions, persist  for  a  longer  time,  possibly  for  weeks. 

Local  Treatment. — Twenty  or  thirty  drops  of  guaiacol 
should  be  sprinkled  on  a  layer  of  cotton.  This  is  wrapped  around 
the  joint,  covered  with  oiled  silk,  and  bandaged  in  place.  The 
joint  should  be  immobilized  by  a  splint  or  sling.  The  initial 
pain  is  much  relieved  in  this  manner.  In  a  few  days  hot  fomen- 
tations or  baking  are  indicated.  When  pain  has  disappeared  and 
the  swelling  is  diminishing,  massage  and  active  and  passive  mo- 
tion of  the  joint  is  advisable.  At  a  still  later  period  it  is  some- 
times desirable  to  give  an  anesthetic  in  order  to  break  up  adhesions. 
This  should  never  be  done  until  all  signs  of  acute  inflammation 
have  passed. 

During  the  painful  stage  of  rheumatism  of  the  wrist  or  fingers, 
the  hand  and  fingers  should  be  constantly  extended.  This  position 
is  favorable  to  subsequent  treatment  of  any  adhesions  which  form, 
for  it  is  much  easier  to  gradually  flex  a  stiff,  extended  joint  than  to 
extend  one  which  is  adherent  in  the  position  of  flexion.  There- 
fore, if  these  joints  are  flexed  or  partly  flexed,  when  the  patient  is 
seen  for  the  first  time,  a  splint  should  be  applied,  to  prevent  in- 
crease of  flexion,  and  each  day  a  slight  extension  of  the  part 
should  be  made  and  the  splint  reapplied  in  the  better  position. 

Gonorrheal  Arthritis.- — In  about  ten  per  cent  of  the  cases 
of  gonorrhea  some  joint  is  involved.  This  occurs  in  the  third  or 
fourth  week  of  the  disease,  or  still  later.     This  lesion  is  often 


434  INFLAMMATIONS  OF  THE   ARM  AND  HAND 

spoken  of  as  a  monarticular  one,  and  so  it  frequently  is;  but  the 
fact  should  not  be  lost  sight  of  that  in  more  than  half  of  the  cases 
of  gonorrheal  arthritis,  more  than  one  joint  is  involved.  However, 
the  inflammation  does  not  skip  from  joint  to  joint,  as  in  rheuma- 
tism, but  pursues  a  tedious  course  of  four  weeks  or  more  in  each 
joint  that  is  affected.  Other  distinguishing  marks  are  the  effu- 
sion into  the  joint  cavity,  edema  of  the  soft  parts,  involvement  of 
any  bursa?  or  tendon  sheaths  in  the  immediate  vicinity  of  the 
joint,  and  the  moderate  character  of  the  pain  and  tenderness. 

The  treatment  is  similar  to  that  for  articular  rheumatism:  rest 
on  a  splint,  with  hot  or  cold  applications  to  relieve  pain  during 
the  first  stage;  then  baking,  followed  by  massage,  and  passive 
and  active  motions.     Restoration  of  function  is  usually  complete. 

Deforming  Arthritis. — This  disease  is  also  known  by  the 
Dames  osteitis  deformans,  rheumatoid  arthritis,  and  others.  It  is 
characterized  by  slight  swelling,  pain,  and  tenderness  of  the  vari- 
ous joints  of  the  body,  and  alterations  of  the  articular  ends  of 
the  bones  due  to  deposits  of  lime  salts.  The  range  of  motion  in 
the  joints  is  thereby  greatly  interfered  with,  and  various  deformi- 
ties are  produced,  such  as  flexion,  overextension,  or  lateral  dis- 
placements. 

When  advanced,  this  disease  is  unmistakable ;  in  its  beginning 
it  may  be  mistaken  for  articular  rheumatism  or  gout.  It  has  not 
the  fever  nor  pain  of  the  former,  nor  the  chalky  skin  deposits, 
and  usually  not  the  nephritic  symptoms  of  the  latter. 

Local  treatment  consists  in  maintaining  and,  if  possible,  in- 
creasing the  range  of  motion  of  the  joints  during  the  periods  of 
quiescence  of  the  disease.  The  affected  limbs  should  be  baked  to 
300°  F.,  if  the  patient  can  stand  it,  and  then  vigorously  massaged 
either  manually  or,  still  better,  by  mechanical  vibration.  Active 
motion  should  be  encouraged  for  the  sake  of  both  joints  and  mus- 
cles. The  use  of  splints  is  contraindicated,  since  immobilization  in 
these  cases  reduces  still  further  the  range  of  motion.  Sometimes 
increased  motion  may  be  obtained  by  manipulation  under  an  anes- 
thetic, but  such  increased  freedom  is  not  generally  permanent.  In 
this,  as  in  most  joint  adhesions,  a  slight,  gentle  motion,  many 
times  repeated,  has  a  far  greater  permanent  good  effect  in  increas- 
ing the  range  of  motion  of  the  joint  than  an  occasional  violent 
motion. 


SYPHILIS  435 

Gout. — While  early  attacks  of  gout  are  often  confined  to  the 
metatarsophalangeal  joint  of  the  great  toe,  they  are  common 
enough  in  some  of  the  smaller  joints  of  the  upper  extremity.  The 
family  history,  and  symptoms  of  gout  manifested  by  the  heart, 
kidneys,  and  gastrointestinal  tract  will  usually  indicate  the  true 
diagnosis.  The  affected  joint  (or  joints)  is  swollen,  hot,  red,  pain- 
ful, and  tender,  similar  to  the  joint  affected  by  articular  rheuma- 
tism. Other  joints  should  be  examined  for  evidences  of  previous 
attacks,  and  uratic  deposits  looked  for  in  the  skin  of  the  hands, 
feet,  and  ears. 

The  extreme  tenderness  and  pain  usually  last  only  a  day  or  two. 
During  this  time  pain  may  be  lessened  by  guaiacol  applied  on  cot- 
ton and  covered  with  oiled  silk,  or  ice  cloths  may  be  applied,  or  the 
patient  may  find  very  hot  applications  more  comforting.  The  best 
and  simplest  way  to  apply  moist  heat  is  to  wrap  the  joint  with  hot 
moist  compresses,  cover  these  with  oiled  silk,  and  then  to  increase 
and  keep  up  the  heat  by  laying  hot  bottles  or  bags  on  either  side  of 
the  limb.  These  can  be  changed  from  time  to  time.  In  this  way 
the  temperature  can  readily  be  kept  as  high  as  the  patient  can  bear 
it,  and  the  inner  dressing  need  not  be  touched.  If  it  dries,  the 
protective  should  be  opened,  and  hot  water  poured  upon  the  com- 
presses. Various  counter-irritants  are  also  employed.  Tincture 
of  iodine  is  the  cleanest,  and  perhaps  as  good  as  any.  When  the 
attack  has  passed  over,  massage  is  beneficial,  as  these  patients 
usually  take  too  little  exercise. 

If  the  gouty  deposit  of  urates  is  large,  or  is  so  situated  that  it 
will  interfere  with  the  use  of  the  member,  or  if  it  is  very  painful, 
it  should  be  removed.  This  can  easily  be  done  under  a  local  anes- 
thetic. The  wound  heals  as  promptly  as  any  clean  wound.  An 
isolated  nodule  in  an  unusual  situation  has  been  mistaken  for  a 
tumor. 

Syphilis. — Lesions  of  syphilis  at  every  stage  are  found  in  the 
hand  and  arm.  The  primary  sore  or  chancre  has  several  times 
developed  upon  the  forefinger  of  a  physician  after  examination 
of  a  syphilitic  patient.  A  chancre  may  also  develop  after  contact 
of  the  hand  with  the  teeth  of  a  syphilitic  patient.  Such  a  case 
is  illustrated  in  Figure  215. 

Late  lesions  of  syphilis  are  often  found  in  the  upper  extremity. 
Eczema  of  the  fingers  is  mentioned  on  page  431.  Gumma  of  the 
30 


436 


INFLAMMATIONS   OF   THE   ARM   AND    HAND 


skin  forming  an  ulcer  (Figs.  216  and  217)  has  the  usual  char- 
acteristics of  gumma  in  other  Paris  of  the  body,  and  demands  the 
usual  treatment.     (See  p.  61.) 


Fig.  215. — Primary  Lesion  of  Syphilis  Developing  in  a  Wound  of  the  Finger 
Made  by  Human  Teeth.     Photograph  eleven  weeks  after  injury. 

Syphilitic  Dactylitis. — When  the  soft  tissues  of  the  joints  of 
the  ringers  become  gummatous,  or  a  gumma  forms  in  one  of  the 
phalanges,  the  condition  is  called  syphilitic  dactylitis.  The  af- 
fected portion  of  the  finger  is  spindle-shaped  or  spherical,  the  shin 


Fig.  216. — Syphilitic  Ulcer  of  the  Hand,  of  Four  Months'  Duration.     Patient 
a  male  aged  thirty-seven  years. 


Fig.' 217. — The  Same  Hand  as  Shown  in  Fig.  216;  After  Four  Weeks  of  Treat- 
i  ment  by  iodid  and  mercury. 


Fig.    218. — Chronic    Inflammation    of    Hand    with    Sinuses    of    Two    Years' 
Duration;  Probably  Syphilitic.     Patient  a  man  aged  fifty-five  years. 

437 


43$  [NFLAMMATIONS   OF  THE   ARM    AND   ELAND 

is  dusky  red  and  shiny,  the  underlying  tissues  are  firm  or,  later, 
boggy,  and  flexion  of  the  joint  is  interfered  with  by  the  swelling, 
although  abnormal  lateral  motion  is  possible.  The  amount  of  pain 
varies  in  different  cases,  and  may  be  wholly  wanting.     After  some 


Fig.  219. — Syphilis  of  Left  Wrist,  Left  Forefinger,  and  Right  Ring-finger, 
Commencing  One  Year  Ago  in  the  Ring-finger,  a  Part  of  which  was 
Amputated  by  a  Physician.     Patient  a  woman  aged  thirty-six  years. 

weeks  or  months  the  skin  may  break  and  allow  the  discharge  of 
characteristic  syrupy  fluid.  The  discharge  afterward  becomes 
pnrnlent  (Fig.  218).  The  formation  of  sinuses  may  not  take 
place  for  months,  or  recovery  may  occur  without  any  sinuses  being 
formed.  In  other  cases  there  is  necrosis  of  bone  which  keeps  open 
the  sinuses. 

Differential  diagnosis  with  tuberculous  dactylitis,  sarcoma,  and 
chronic  purulent  synovitis  may  be  extremely  difficult.  An  exact 
history  of  the  case,  a  radiograph,  two  weeks'  treatment  with  iodid 
of  potash,  with  a  splint  and  wet  dressings  to  the  finger  if  the  joint 
has  been  opened,  will  almost  always  dispel  the  doubt.  Amputation 
should  never  be  resorted  to  in  syphilitic  cases,  as  recovery  is  almost 
always  perfect  if  internal  treatment  is  persisted  in.     Moreover, 


TUBERCULOSIS  OF  TENDON  SHEATHS 


439 


amputation  is  no  preventive  of  recurrence  (Fig.  219),  even  in  the 
stump  of  the  amputated  finger. 

Tuberculosis  of  Tendon  Sheaths. — There  is  also  a  chronic 
inflammation  of  the  tendon  sheaths,  due  to  the  tubercle  bacillus, 
at  least  in  most  cases.  Either  the  flexor  or  extensor  tendons  may 
be  involved  (Figs.  220  and  221).  The  sheaths  of  the  tendons  are 
gradually  distended  with  fluid  which  is  at  first  serous,  but  which 
later  contains  rice  bodies.  These  are  fibrinous  bodies  about  as 
large  and  about  as  slippery  as  wet  melon  seeds.  They  can  often 
be  detected  by  palpation,  and  can  often  be  made  to  slip  back  and 
forth  under  the  annular  ligament  from  one  relaxed  portion  of  the 


Fig.  220. — Tuberculosis  of  Flexor  Tendon  Sheaths  of  Hand.     Especial  dis- 
tention of  sheath  of  middle  finger;  sinus  in  palm.     Patient  a  boy  aged  six  years. 


sheath  to  the  other.  The  condition  may  remain  about  the  same 
for  months,  causing  little  or  no  pain,  and  no  swelling  of  the 
tissues  outside  of  the  sheaths ;  or  the  tubercular  process  may  be 
more  active,  giving  pain  and  edema,  with  a  discharge  of  pus  and 
detritus  into  the  cavity  of  the  sheath,  or  through  the  skin. 


11(1 


INFLAMMATIONS   OF   THE    ARM   AND   HAND 


Fig.  221. — Tenosynovitis,  Probably  Tl'hercular,  of 
Five  Months'  Duration.  Patient  a  man  aged  forty- 
nine  years. 


Treatment. — The  only  treatmenl  to  be  advised  is  the  com- 
plete removal  of  the  affected  tendon- sheaths  by  dissection  under  a 

general    anesthetic. 
If  this  operation  is 

performed  at  an 
early  stage,  the 
wounds  may  be  su- 
i  tired,  and  will  usu- 
ally unite  primar- 
ily. Slight  active 
motions  should  be 
begun  in  a  week  to 
prevent  permanent 
adhesions.  There 
is  in  many  cases 
full  restoration  of 
function.  Opera- 
tions performed  in 
the  suppurative  stage,  or  after  the  disease  has  extended  beyond  the 
synovial  membrane,  do  not  have  so  favorable  a  result. 

Tuberculosis  of  Joints. — In  tuberculous  arthritis  of  the  up- 
per extremity  the  disease  may  begin  in  the  synovial  membrane,  or, 
more  commonly,  in  the  extremity  of  one  of  the  bones  forming  the 
joint.  In  the  latter  case  it  usually  extends  into  the  joint,  but  not 
necessarily  so,  as  it  may  extend  in  the  other  direction,  and  when 
suppuration  takes  place  the  pus  may  break  through  the  skin  with- 
out having  entered  the  joint.  In  the  usual  case,  however,  the 
•joint  is  early  involved,  and  the  tuberculous  arthritis  which  then 
exists  must  be  differentiated  from  the  various  other  chronic  in- 
flammations of  a  joint. 

Symptoms. — The  early  symptoms  of  tuberculous  arthritis  are 
local  heat,  swelling,  limitation  of  motion,  partial  loss  of  function, 
usually  pain  and  tenderness,  and  muscular  atrophy.  This  last  is 
a  symptom  which  occurs  early  in  the  disease,  and  is  almost  always 
demonstrable  when  the  doctor  first  sees  the  patient.  Muscular 
spasm,  which  is  so  prominent  a  symptom  in  tuberculosis  of  the 
joints  of  the  lower  extremity,  is  not  so  easily  produced  in  the  joints 
of  the  upper  extremity.  These  various  symptoms  are  worth  further 
attention. 


TUBERCULOSIS   OF   JOINTS 


441 


Local  heat  is  readily  determined  by  comparing  the  affected 
joint  with  other  parts  of  the  same  limb,  and  with  the  correspond- 
ing joint  of  the  opposite  limb. 

Swelling  should  be  measured  circumferentially  in  inches  or 
centimeters,  not  guessed  at.  It  is  a  good  plan  to  measure  at  the 
same  time  the  circumferences  of  both  limbs  a  certain  distance 
above  and  below  the  plane  of  the  affected  joint,  to  determine  the 
presence  of  atrophy. 

Limitation  of  motion,  both  active  and  passive,  is  ascertained 
by  testing  the  various  normal  motions  of  the  joint,  one  after  the 
other,  to  the  fullest  possible  extent.     A  goniometer  is  an  instru- 


Fig.  222, 


-Diagram  to  Aid  the  Eye  in  Estimating  the  Range  of  Motion  in  a 
Joint. 


ment  to  measure  the  range  of  motion,  but  this  can  be  estimated 
with  sufficient  accuracy  by  the  eye,  if  one  bears  in  mind  that  two 
bones  at  right  angles  to  each  other  make  an  angle  of  90  degrees ; 
in  the  same  line  they  make  an  angle  of  ISO  degrees;  while  mid- 
way between  a  right  angle  and  a  straight  line  they  make  an  angle 
of  135  degrees.  If  the  quadrant  in  question  is  divided  into  thirds, 
the  angles  will  be  120  degrees  and  150  degrees  (Fig.  222). 


442  INFLAMMATIONS   OF   THE   ARM   AND   HAND 

Loss  of  fund  ion  may  be  due  to  limitation  of  motion  or  to  loss 
of  muscular  power,  or  to  the  pain  which  use  of  the  joint  elicits. 
It  should  be  noted  in  the  history  in  exact  terms  for  future  com- 
parison. 

Pain  and  tenderness  vary  much  in  different  patients.  Pre- 
sumably they  are  greater  when  there  is  an  unruptured  focus  of 
disease  in  a  bone  than  when  such  a  focus  has  ruptured  or  when 
the  disease  is  exclusively  in  the  synovia  or  other  soft  tissues. 

A  radiograph  shows  the  tuberculous  bone  to  be  distended  and 
decalcified. 

At  a  later  stage  there  is  often  fluctuation,  due  to  fluid  within 
or  outside  of  the  joint;   and   there  may  be  abscesses  or  sinuses. 


Fig.  223. — Tuberculosis  of  the  Wrist,  One  Year,  with  Sinus.     Patient  a  man 
aged  twenty-nine  years. 

Discharge  of  pus  through  a  sinus,  of  course,  reduces  the  swelling. 
The  sinus  often  becomes  blocked  and  the  swelling  and  other  acute 
symptoms  reappear  until  relief  is  again  obtained  by  discharge 
through  the  same  or  another  sinus  (Fig.  223).  If  a  probe  will 
follow  such  a  sinus  it  will  either  enter  the  joint  or  touch  diseased 
bone.- 

Tuberculosis  of  the  upper  extremity  is  rare  in  both  childhood 
and  in  adult  life.  The  statistics  of  different  observers  vary,  but  it 
is  probably  safe  to  say  that  of  all  cases  of  tuberculosis  of  joints 
of  the  extremities,  not  more  than  two  per  cent  fall  to  the  shoulder- 


OSTEOMYELITIS  443 

joint,  two  or  three  per  cent  to  the  elbow-joint,  and  less  than  one 
per  cent  to  the  wrist- joint  and  bones  of  the  hand,  giving  a  total 
of  about  five  per  cent  for  all  the  joints  of  the  upper •  extremity. 

Tuberculosis  in  the  hand  itself,  or  of  the  fingers,  may  be  situ- 
ated in  the  joints,  or  it  may  involve  the  shaft  of  one  of  the  longer 
bones.  In  the  latter  case  a  fusiform  swelling  is  given  to  the 
affected  part,  the  center  of  the  swelling  being  midway  between  the 
joints ;  whereas,  in  arthritis  of  whatever  nature,  the  center  of  the 
swelling  is  opposite  the  plane  of  the  joint.  In  syphilis  there  may 
be  either  type  of  swelling. 

Treatment. — The  first  treatment  of  tuberculous  arthritis  is  to 
keep  the  joint  at  rest  by  splints  or  plaster  of  Paris  bandage.  If 
fluid  accumulates  and  causes  pain  or  distends  the  skin,  it  should 
be  evacuated  through  a  small  incision. 

Injections  of  iodoform  (ten  per  cent  in  glycerin)  and  other 
substances  into  the  tissues  around  the  diseased  foci  have  been  favor- 
ably spoken  of  by  some  surgeons,  but  their  use  is  often  disap- 
pointing. 

If  necrosis  of  a  bone  develops,  the  necrotic  portion  must,  of 
course,  be  removed.  Suitable  splints  should  be  worn  until  recovery 
is  complete  to  limit  the  amount  of  the  deformity  as  far  as  possible. 

The  tendency  of  tuberculosis  of  a  joint  in  infancy  and  child- 
hood is  often  toward  recovery.  Such  a  favorable  outcome  may  be 
hoped  for  in  adults,  but  it  is  far  less  frequent.  If  a  reasonable  time 
has  been  given  to  simpler  measures  and  the  condition  of  the  patient 
does  not  improve,  resection  or  amputation  must  be  considered  not 
only  to  terminate  the  local  process,  but  to  save  the  patient  from 
extension  of  the  disease  to  some  other  part  of  the  body.  These  are 
operations  fully  discussed  in  books  upon  major  surgery.  The  re- 
sults of  resection  are  often  not  much  worse  than  those  which  follow 
a  spontaneous  cure,  since  more  or  less  disability  often  remains. 
Hence,  in  an  adult  one  should  not  put  off  too  long  the  question  of 
operation.  It  is  hardly  necessary  to  add  that  whatever  the  local 
treatment,  constitutional  hygienic  and  dietetic  treatment  is  even 
more  important.  Out-of-door  life  will  cure  nearly  all  cases  of 
joint  tuberculosis  in  children. 

Osteomyelitis. — Inflammation  of  bone,  without  or  with 
necrosis,  may  follow  suppuration  in  the  wound  of  a  compound 
fracture  (p.  386),  or  in  a  joint  which  has  been  wounded  (p.  423). 


444  INFLAMMATIONS   OF   THE   ARM    AND   HAND 

There  is  also  a  suppurative  inflammation  of  bone,  situated  usually 
in  the  shaft  or  epiphysis,  coming  on  without  such  evident  trau- 
matic origin,  and  known  as  osteomyelitis,  lu  a  well  marked  case 
there  is  a  high  fever,  a  chill,  and  intense  pain  in  the  hone,  followed 
by  convulsions  or  delirium,  for  the  disease  is  oeiierallv  in  childhood 
or  adolescence.  There  are  also  milder  cases,  with  less  pain  and 
slight  fever.  Pain  is  invariably  increased  when  the  affected  hone 
is  jarred.  After  the  pus  distends  or  breaks  through  the  perios- 
teum, there  are  the  usual  signs  of  abscess  in  the  soft  parts. 

Osteomyelitis  is  about  five  limes  more  common  in  the  lower 
extremity  than  in  the  upper.  Its  early  recognition  is  of  the  great- 
est importance.  Free  exit  should  be  given  to  the  pus  by  an  in- 
cision through  the  periosteum,  and  if  the  pus  is  not  then  reached 
the  bone  should  be  opened  with  drill  or  chisel.  Such  prompt  treat- 
menl  will  often  save  the  life  of  the  patient,  and  may  even  permit 
recovery  without  necrosis  of  the  bone,  though   this  is  rare. 


CHAPTER    XVI 
TUMORS  AND  DEFORMITIES  OF  THE  ARM  AND  HAND 

TUMORS 

Ganglion. — There  is  a  cystic  tumor  often  found  in  the  upper 
extremity,  and  especially  about  the  wrist,  which  is  called  a  gan- 
glion. It  consists  of  a  fibrous  capsule,  intimately  connected  with 
the  capsule  of  a  joint,  or  with  a  tendon  sheath,  and  a  synovial 
lining,  and  it  is  filled  with  a  thin,  clear,  sirupy  fluid.  Its  cavity 
may  or  may  not  be  continuous  with  the  cavity  of  the  joint  or 
tendon  sheath.  The  origin  of  a  ganglion  is  a  matter  of  dispute. 
Some  observers  believe  that  it  is  a  true  hernia  of  the  joint  capsule, 
and  others  assert  that  it  is  a  fibrous  tumor,  growing  from  the 
fibrous  capsule  of  the  joint  or  tendon  sheath,  the  center  of  which 
undergoes  degeneration,  and  contains  fluid  ;  and  that  this  degen- 
eration may  extend  until  the  cavity  of  the  joint  is  opened. 


Fig.  224. — Ganglion  of  Wrist.     Patient  a  man  aged  fifty-nine  years. 

445 


446    TUMOliS  AND  DEFORMITIES   OF   THE   ARM    AND   HAND 

The  most  common  situation  for  a  ganglion  is  the  back  of  the 
wrist,  in  the  space  between  the  tendon  of  the  long  extensor  of 
the  thumb  and  the  long  extensor  of  the  index-finger,  where  it  is 
intimate] v  connected  with  the  capsule  of  the  joint.  It  frequently 
follows  some  overexertion,  and  the  patient  will  say  that  he  felt 
something  give  in  the  wrist-joint.  A  few  days  later  a  little  puffi- 
ness  will  appeal-,  which  will  increase  in  size  and  hardness  as  time 
goes  on.  Such  a  tumor  may  remain  for  months  without  much 
alteration,  or  it  may  gradually  increase  in  size  while  tending  to 
weaken  the  joint  and  to  make  its  use  painful.  There  is  usually 
very  little  pain  in  the  tumor  when  the  hand  is  kept  at  rest.  The 
overlying  skin  is  freely  movable  and  is  not  altered  in  appearance 
(Fig!  224). 

If  left  to  itself  a  ganglion  tends  to  increase  slowly  in  size 
until  it  is  an  inch  or  more  in  diameter. 

Treatment. — The  old  treatment  for  a  ganglion  was  to 
make  it  tense  by  flexing  the  hand,  and  then  to  rupture  it  by  a 
sharp  blow  with  a  heavy  book.  If  the  blow  succeeds  in  breaking 
the  sac  the  fluid  contents  escape  into  the  surrounding  tissue. 
Pressure  made  by  means  of  a  coin  and  a  strap  of  adhesive  plaster 
for  a  couple  of  weeks  may  cause  the  sac  walls  to  grow  together 
and  so  to  obliterate  the  cavity.  Usually  the  cavity  refills  and  the 
patient  is  as  bad  off  as  ever.     It  often  happens  also  that  the  wall 


1^? 


Fig.  225. — Ganglion  of  the  Wrist.     Lateral  view  to  show  the  elevation  of  the 

tumor. 

of  the  sac  is  so  firm  that  it  will  not  rupture,  or  that  the  amount 
of  fluid  contained  in  the  tumor  is  so  slight  that  its  size  is  not 
much  diminished  by  its  removal.  A  more  rational  treatment  con- 
sists in  the  complete  removal  of  the  tumor  through  a  longitudinal 
incision,  the  connection  with  the  joint  being  closed,  if  it  exists, 
by  a  ligature  or  a  suture.    This  operation  may  be  performed  with  a 


GANGLION 


447 


local  anesthetic,  as  the  tissues  are  readily  anesthetized.  A  longi- 
tudinal incision  is  then  made  in  the  skin,  about  half  an  inch 
longer  than  the  diameter  of  the  tumor  (Fig.  225).  The  tissues 
are  carefully  divided  until  the  fibrous  capsule  of  the  ganglion  is 
reached.  The  top  and  sides  of  the  ganglion  are  then  fully  ex- 
posed by  blunt  dissection  (Fig.  220).     If  the  ganglion  is  a  small 


Fig.  226. — Ganglion  of  the  Wrist.  The  skin  has  been 
incised  and  reflected  back  from  the  surface  of  the 
tumor. 


one,  and  Las  a  slender  pedicle,  this  blunt  dissection  may  be  con- 
tinued all  around  and  beneath  it  until  it  is  lifted  from  its  bed, 
and  the  pedicle  is  ready  for  the  ligature.  In  most  cases,  however, 
time  is  saved,  and  the  dissection  is  rendered  easier  and  less  pain- 
ful by  opening  the  ganglion  and  evacuating  its  contents  as  soon 
as  the  sides  of  the  capsule  have  been  dissected  free.  It  should 
then  be  split  throughout  its  length  so  that  the  surgeon  may  obtain 
a  clear  view  of  its  base  and  attachments.  Nothing  is  to  be  gained, 
and  needless  injury  may  be  inflicted  by  the  attempt  to  remove  it 
before  it  is  opened,  for  the  dissection  of  the  base  is  the  most  diffi- 
cult part  of  the  operation,  and  the  only  part  which  it  is  hard 
to  make  absolutely  painless.-  The  whole  of  the  sac  should  be  dis- 
sected away,  and  its  attachment  ligated  and  divided  (Fig.  227). 
If  the  sac  is  closely  attached  to  bone,  ligaments,  or  tendons,  the 
outer  portion  of  the  sac  may  be  left  as  long  as  its  lining  is  removed. 
A  ganglion  sometimes  recurs  after  a  careful  excision. 

Another  method  of  treatment  which  often  yields  a  prompt  and 
painless  cure  is  the  injection  into  the  sac  of  the  ganglion  of  twenty 
or  thirty  minims  of  a  mixture  of  equal  parts  of  crystals  of  chloral 
hydrate  and  carbolic  acid.  These  two  crystals  when  mixed  imme- 
diately form  a  fluid  sufficiently  thin  for  injection  through  an  ordi- 


IIS    TUMORS  AND  DEFORMITIES  OF  THE  ARM  AND  HAND 

nary  hypodermic  needle.  Before  making  the  injection  it  is  desira- 
ble to  withdraw  the  greater  part  of  the  contents  of  the  ganglion. 
Sometimes  the  contents  are  fluid;  more  often  they  are  like  jelly. 
Hence  the  aspiration  should  be  made  with  a  needle  of  large  cali- 


ismr*     "^ww 


Fig.  227. — Ganglion  of  Wrist,  Showing  the  Ligation  of  the  Sac. 

her,  and  the  suction  must  be  supplemented  by  strong  pressure  upon 
the  sac.  The  injection  of  the  carbolic  mixture  causes  little  if  any 
pain.  There  may  be  some  edema  for  a  couple  of  days,  but  soon 
the  sac  shrinks,  and  may  entirely  disappear  after  a  single  injec- 
tion. Unfortunately,  the  cure  thus  easily  obtained  is  not  always 
permanent. 

Another  method  of  treatment  is  the  insertion  of  a  needle  by 
means  of  which  numerous  punctures  are  made  through  the  sac, 
and  its  lining  is  scratched,  and  indeed  the  sac  itself  is  torn  to 
pieces  as  far  as  possible.  This  procedure  should  be  followed  by 
continuous  pressure  for  several  days  to  obliterate  the  space  in 
which  the  fluid  was  contained. 

Aneurism. — An  arterial  aneurism,  the  result  of  a  punctured 
wound,  is  sometimes  seen  in  the  hand  or  wrist.  When  an  aneu- 
rism due  wholly  to  internal  causes  develops  in  the  upper  extrem- 
ity, it  is  likely  to  be  found  in  the  brachial  artery. 

These  tumors  are  small,  smooth,  elastic,  compressible,  and 
pulsating.  They  can  lie  mistaken  for  some  tumor  overlying  a 
normal  vessel.     Thus  a  ganglion  of  the  wrist  may  lie  on  the  radial 


VARIX 


449 


artery  and  transmit  the  pulsation  from  the  vessel,  just  as  a  cold 
abscess  may  transmit  pulsation  from  an  underlying  artery.  A 
careful  examination  will  differentiate  this  transmitted  pulsation 
from  a  true  expansile  pulsation. 

The  hest  treatment  for  aneurism  of  the  upper  extremity  is  dis- 
section and  ligation  of  the -vessel  involved  both  above  and  below 
the  aneurism  with  chromic  catgut.     The  blood-supply  is  so  free 
that  gangrene  need  not  be  feared.     "The  wound   should  be  com 
pletely  sutured. 

Varix. — One  or  more  veins  may  be  dilated,  forming  either  a 
single  smooth  swelling  (Fig.  22S)  or  a  more  or  less  dilated  and 


Fig.   228. — Nevus   of  Hand,   of  Seven  Years'  Duration.     Patient  a  girl  aged 
ten  years.     The  tumor  disappeared  completely  when  the  hand  was  held  up. 


tortuous  one  (Fig.  229).  Such  a  dilation  is  called  a  venous 
aneurism  or  a  varix.  If  such  a  tumor  connects  with  an  artery, 
it  may  pulsate  faintly.     A  characteristic  sign  is  its  almost  com- 


450    TUMORS  AND  DEFORMITIES  OF  THE  ARM  AND  HAND 


plete  disappearance  on  steady  compression,  combined  with  eleva- 
tion of  the  arm,  and  its  reappearance  as  soon  as  the  pressure  is 
removed.  It  is  also  softly  fluctuating  and  gives  a  bluish  shade 
to  the  overlying  skin. 

The  treatment  is  the  double  ligation  of  the  vessels  with  or 
without  removal  of  the  dilated  portion.  If  a  removal  of  the  ves- 
sels is  decided  upon, 
it  is  well  to  place 
an  Esmarch  bandage 
around  the  arm  he- 
fore  operation,  and  to 
ligate  all  visible  cut 
vessels  before  remov- 
ing the  bandage,  as 
bleeding  from  these 
dilated  veins  is  very 
free.  If  an  Esmarch 
bandage  is  not  em- 
ployed, the  dissection 
and  ligation  should  be 
carried  on  from  below 
upward  in  order  to 
avoid  cutting  and  li- 
ghting the  same  vessel 
several  times. 

Inclusion  Cyst. 
— Sebaceous  cysts  do 
not  occur  in  the  hand, 
but  similar  cysts,  lined 
with  epithelium,  are 
found  in  the  skin  of 
the  palm.  They  are  thought  to  be  due  to  inclusion  of  epithelial 
cells,  either  during  the  embryonic  period  or  postnatally,  as  a 
result  of  traumatism  (Fig.  230).  A  cyst  of  this  character  is 
smooth,  tense,  possibly  fluctuating,  and  intimately  attached  to  the 
skin,  which  cannot  be  moved  over  it.  It  most  nearly  resembles  a 
fibroma  in  physical  characteristics.  It  should  be  removed  entirely. 
This  can  usually  be  performed  in  such  a  manner  that  the  wound 
can  be  closed  by  sutures.     If  not,  the  resulting  small  granulating 


Fig.  229. 


-Extensive  Tortuous  Varices  of  Hand 
and  Arm. 


LIPOMA  451 

wound  will  soon  become  covered  by  growth   of  epithelium    from 

its  ede;es. 


Fig.  230. — Inclusion  Cyst  of  Palm. 


Lipoma. — This  is  a  common  tumor  in  the  upper  extremity, 
where  it  occurs  both  singly  and  in  groups.  A  simple  lipoma  (Fig. 
231),  having  the  characteristics  already  described  on  page  137, 
when  it  occurs  in  the  arm,  can  hardly  be  mistaken  for  anything 


Fig.  231. — Simple  Lipoma  of  Akm. 


else ;  in  the  hand  it  may  be  confused  with  fibroma,  or  one  of  tlie 
other  tumors  mentioned  below.     The  technique  of  its  removal  is 
given  on  page  137. 
31 


I.VJ     "IT.MnllS    AMI    DEFORMITIES    ill'    THE    AEM    AND    HAND 

Multiple  Lipomata. — Lipomata  of  the  arm,  occurring  in  groups, 
appear  to  be  hereditary.  The  tumors  are  situated  in  the  subcu- 
taneous plane  of  fatty  tissue,  and  can  be  easily  removed;  but  as 
they  do  no  harm,  and  evince  no  tendency  to  malignancy,  their  re- 
moval is  not  indicated  except  upon  esthetic  grounds. 

Fibroma  and  Fibroliponia. — Fibroma  occurs  as  a  smooth, 
flabby,  or  firm  tumor,  either  in  or  closely  all  ached  to  the  shin. 
It  grows  slowlv,  usually  without  pain.  It  is  not  compressible, 
as  a  varix  is;  it  lias  a  uniform  consistence1,  and  is  covered  by  nor- 
mal shin  (Figs.  232,  233,  and  234).     A  tumor  of  this  character 


Fig.  232. — Fibroma  of  Middle  'Finger.     Duration  six  years.     Thought  to  have  de- 
veloped from  the  sting  of  some  insect.     Patient  a  man  aged  forty-five  years. 

often  gives  a  distinct  wave  of  fluctuation,  which  is  very  decep- 
tive. There  is  usually  this  difference,  however :  Fluid  in  a  firm 
sac,  if  pressed  upon,  will  give  a  much  quicker  fluctuation  wave 
than  when  no  outside  pressure  is  applied.  Outside  pressure  upon 
a  solid  tumor,  such  as  a  soft  fibroma,  has  little  effect  upon  its 
fluctuation  wave,  since  the  pressure  is  not  at  once  distributed 
equally  in  all  directions. 

A  fibroma  may  contain  fat,  and  is  then  often  spoken  of  as  a 
fibrolipoma.  This  makes  a  softer  tumor  than  a  pure  fibroma. 
The  differentiation  between  fibroma  and  lipoma  is  not  very  im- 
portant, since  the  prognosis  and  treatment  are  similar. 

It  is,  however,  very  important  to  differentiate  fibroma  and 


FIBROMA   AND   FIBROLTPOMA 


453 


sarcoma.     At  an  early  stage  of  the  latter  this  may  be  impossible 
except  by  •  microscopic  examination.      Both   may  be  soft  or  hard. 


Fig.   233. — Same   Subject  as  Fig.   232.     Radiograph  showing  the  bone  not  to  be 
affected.     Compare  Figs.  236  and  237  on  pp.  455  and  456. 

The  safe  plan  is  to  remove  every  growing  tumor,  and  to  subject 
it  to  microscopic  examination.     The  wound  should  he  closed  by 


Fig.  234. — Fibroma  of  Hand. 


454     TUMORS  AM)   DEFORMITIES   01    THE   A.RM    A.ND   HAND 


suture,  in  order  to  awail  the  reporl  of  the  pathologist  after  his 
examination  of  numerous  sections  of  the  Lardened  tumor.  In 
such  a  case  it  would  be  unwise  to  base  the  extent  of  operation  upon 

an  examination  of  frozen  sections;  for  the  similarity  of  fibroma 
to  some  forms  of  sarcoma  is  so  great  that  a  positive  decision  is 
difficult,  even  from  the  very  best  sections. 

If  it  is  found  that  the  tumor  is  a  fibroma  no  further  operation 
is  necessary,  and  the  patient  has  been  spared  the  unnecessary  loss 
of  time.  If  it  proves  to  be  a  sarcoma,  a  further  extensive  removal 
of  adjacent  tissue  will  be  necessary.  It  has  been  my  experience 
that  patients  will  almost  invariably  submit  to  a  second  operation, 
should  such  be  found  necessary,  if  the  exact  plan  of  procedure  is 
explained  to  them  before  the  first  operation. 

In  some  cases  a  fibroma  may  be  mistaken  for  the  lesions  of 
tuberculosis  or  syphilis.  Such  a  mistake  is  unlikely,  and  should 
soon  be  corrected  by  the  progress  of  the  inflammatory  disease. 


Fig.  235. — Papilloma  of  Wrist;  Fibrolipoma. 

A  ganglion  should  be  differentiated  by  the  fact  that  it  is  cov- 
ered by  movable  normal  skin.  The  skin  over  a  fibroma  is  closely 
attached  to  the  tumor. 

An  inclusion  cyst  is  to  be  known  by  its  development  in  the 
palm,  by  its  fluid  fluctuation  wave,  and  by  its  different  consistency 
near  its  margin  and  at  its  center.. 


NEUROFIBROMA 


455 


Finally,  a  fibroma  may  be  so  hard  as  to  simulate  an  osteoma. 
The  latter  is  of  course  immovable  in  the  bone,  while  the  fibroma 
is  movable,  at  least  to  a  short  distance.  Radiographs  will  clearly 
differentiate  the  two  tumors  (see'  Figs.  237,  p.  450,  and  23!), 
p.  457). 

Papilloma. — A  fibrous  and  fatty  tumor — in  other  words,  a 
fibrolipoma — if  pedicled,   is  called  a  papilloma.      Such    a   tumor 


Fig.  236. — Osteoma  of  Finger. 


is  covered  with  normal  or  slightly  hypertrophied  skin,  and  it  is 
attached  to  the  body  by  a  neck  smaller  than  the  mass  of  the  tumor 
(Fig.  235).  This  type  of  tumor  is  commoner  upon  the  trunk 
than  upon  the  extremities  (see  p.  185). 

Neurofibroma. — Contusion  or  wound  of  a  nerve  may  lead 
to  the  development  of  a  fibrous  tumor  in  the  nerve  trunk.     This 


456    TUMORS   AND   DEFORMITIES   OF   THE   ARM   AND    HAND 

form  of  tumor  reaches  its  maximum  growth  in  the  slumps  of 
nerves  after  amputation,  and  especially  in  the  lower  extremity.  It 
is  also  found  in  the  palmar  nerves  of  the  hand,  under  the  circum- 
stances mentioned,  and  sometimes  causes  the  patient  great  pain. 


Fig.  237. — Same  Subject  as  Fig.  236.  Radiograph  of  osteoma.  Note  commencing 
similar  growths  in  the  first  phalanx  of  the  same  finger,  and  of  the  adjoining 
finger. 

The  best  treatment  is  dissection  and  removal  of  the  visibly  affected 
portion  of  the  nerve,  and  a  clean  division  of  the  trunk  of  the 
nerve,  a  little  above  the  incision  in  the  skin.  This  is  to  lessen 
the  risk  of  pressure  of  its  stump  in  the  scar.  Recurrence  some- 
times takes  place. 

Osteoma. — rOsteoma  of  a  small  bone  has  the  same  character- 
istics as  osteoma  of  a  large  bone,  viz.,  it  is  a  hard  painless  tumor 


OSTEOMA 


457 


of  slow  growth,  covered  by  normal  movable  skin,  while  it  is 
firmly  attached  to  the  bone  from  which  it  grows  (Figs.  236  and 
237).  It  may  be  mistaken  for  a  periosteal  sarcoma,  or  a  dense 
fibrolipoma.  The  former  has  usually  a  more  rapid  growth,  and 
the  latter  is  less  hard,  and  always  somewhat  movable  on  the  under- 
lying bone.  In  such  doubtful  cases  a  radiograph  is  a  necessity 
(Tigs.  238  and  239).  The  radiograph  of  this  osteoma  is  most 
instructive    on   another    account.      Careful   inspection    will   show 


1 

- 'I 

, 

, 

I      z. 

^k. 

1 

"l  1,  '•■ 

I, 

L. 

v 

Fig.  238. — Fibrolipoma  of  Finger. 
Same  subject  as  Fig.  239. 


Fig.  239. — Radiograph  of  Fibrolipoma 
of  Finger  Showing  Normal  Bones. 


that  two  similar  tumors  were  developing  in  the  first  phalanges 
of  the  second  and  third  digits.  Their  presence  was  not  suspected 
until  the  radiographs  were  made,  but  one  of  them  was  palpable 
when  attention  had  been  called  to  it. 


458    TUMORS   AND   DEFORMITIES   OF   THE   ARM   AND   HAND 


An  osteoma  should  be  removed.  The  skin  is  incised  longi- 
tudinally at  a  distance  from  the  tendons,  and  the  osteoma  exposed 
by  dissection  and  retraction  of  the  soft  parts.  The  tumor  should 
then  be  chiseled  away.  It  is  not  necessary  to  remove  the  bone 
from  which  an  osteoma  springs,  unless  there  is  a  suspicion  of 
sarcoma ;  and  even  in  that  case  it  is  better  to  await  the  result  of 
the  microscopical  examination  when  one  can  act  intelligently  and 
as  radically  as  the  facts  warrant. 

Granuloma. — Granulations  may  grow  above  the  surface  of 
a  wound,  and  prevent  the  epidermis  from  growing  over  the  wound. 
Such  exuberant  granulations  are  spoken  of  as  proud  flesh.  They 
may  be  cut  away  with  scissors  and  the  free  bleeding  stopped  with 
pressure  for  a  minute,  or  they  may  be  burned  down  by  touching 

them  with  solid  nitrate  of  sil- 
ver. If  of  long  standing  in  a 
small  wound,  they  become  firm- 
er in  texture  and  pedicled  in 
shape,  and  present  somewhat 
the  appearance  of  a  sarcoma. 
Such  a  mass  is  called  a  granu- 
loma (Fig.  240). 

A  wart  is  a  tumor  of  the 
epidermis,  of  papillary  struc- 
ture and  usually  elevated  above 
the  level  of  the  normal  skin. 
Warts  usually  develop  in  the 
skin  of  the  hands,  and  during 
childhood,  but  they  are  also 
found  in  other  situations  and  in 
adult  life.  Their  cause  is  not 
known.  If  a  wart  is  so  situated 
that  it  can  develop  freely  it  may 
attain  a  height  of  one-eighth  of 
an  inch,  and  a  diameter  of  one- 
third  of  an  inch  or  more.  The 
top  is  flat  and  shows  numerous 
clefts  between  more  actively 
growing  points.  This  gives  the  surface  of  an  old  wart  something 
of  a  cauliflower  appearance  (Fig.  241).     If  situated  where  it  is 


Fig.  240. — Granuloma  of  Finger. 


WART 


459 


irritated,  for  example,  on  the  knuckle  or  along  the  nail,  a  wart 

is  apt  to  crack  and  bleed  and  to  give  some  pain.     If  situated  under 

very  tough  epidermis,   for  example  on  the   palmar  side  of  the 

fingers  or  hand,  the  wart  is  often  confined  in  its  growth,  so  that 

its  papillary  character 

is  less  evident,   and   it 

appears  more  as  a  hard, 

tender    tumor    covered 

by     thick     epithelium 

and  rising  little  above 

the    skin   surface.      If 

the  surface  epithelium 

is  shaved  off,  its  true 

papillary  structure  will 

be  evident. 

Treatment. — The 
warts  that  appear  in 
large  numbers  on  the 
backs  of  the  hands  of 
children,  usually  disap- 
pear spontaneously,  or 
after  some  local  treat- 
ment. Single  warts  oc- 
curring in  adult  life 
are  not  so  easily  dis- 
lodged. They  may  be  removed  by  the  knife  (it  is  only  necessary 
to  remove  the  whole  thickness  of  epidermis — not  the  corium),  or 
by  caustics.  Monochloracetic  acid  is  the  best  for  this  purpose.  A 
small  crystal  should  be  picked  up  with  a  moistened  toothpick  and 
placed  on  the  wart.  The  moisture  will  fuse  the  crystal  without 
diluting  it  unnecessarily. 

After  three  minutes,  or  sooner  if  the  patient  feels  that  it 
burns,  it  should  be  wiped  away.  In  three  days  the  burned  tissue 
should  be  pared  away  and  a  drop  of  acid  be  applied  to  the  living 
tissue  beneath.  This  process  should  be  repeated  as  often  as  is 
necessary  until  the  wart,  including  its  growing  base,  has  been 
completely  destroyed  and  removed.  Too  frequent  applications  of 
acid  will  make  the  part  sore;  too  infrequent  applications  will  allow 
the  wart  to  grow  in  the  intervals  enough  to  make  up  for  the  par- 


Fig.  241. — Old  Wart  of  Index-finger. 


400     TUMORS   AND  DEFORMITIES   OF   THE   ARM   AND    HAND 

tial  destruction.  A  weaker  caustic,  such  as  a  saturated  solution 
of  bichromate  of  potash,  may  be  painted  on  every  day.  This 
treatment  is  more  suitable  to  place  in  the  hands  of  the  patient 
himself.  Treatment  by  acid,  if  judiciously  carried  out,  is  pain- 
less, avoids  the  use  of  any  dressing,  and  the  permanent  loss  of 
any  skin.  Treatment  by  the  knife  is  quicker,  but  it  necessitates 
a  dressing  and  usually  the  loss  of  a  bit  of  skin.  If  the  wart  is 
covered  by  thick  epidermis  (palm  of  hand,  sole  of  foot),  it  can  still 
he  removed  by  acid,  if  the  rules  given  are  persistently  carried  out. 
Here,  however,  the  two  methods  of  treatment  may  he  happily 
combined  by  injecting  cocain  and  shelling  out  the  wart  with  a 
curette,  and  cauterizing  the  base  of  the  wound  with  acid  before 
the  anesthesia  is  over. 

Epithelioma  in  the  upper  extremity  usually  develops  on  the 
back  of  the  hand  in  an  individual  more  than  sixty  vears  old.     It 


Fig.  242. — Metastatic  Carcinoma  of  the  Bones  of  the  Hand  from  Carcinoma 

of  the  Breast. 

may  follow  an  injury,  although  usually  there  is  no  history  of  any 
traumatism  other  than  the  knocks  and  bruises  to  which  the  hand 
of  a  worker  is  frequently  subjected. 

More  often  it  develops  in  one  of  the  scaly  patches  so  common 


EPITHELIOMA 


461 


on  the  hands  of  the  aged.  It  is  generally  of  very  slow  growth, 
appearing  for  months  as  a  shallow  ulcer  wliicli  Meeds  easily  and 
may  heal  in  part  but  not  wholly;  later  the  growing  margin  is  more 


Fig.  243. — The  Site  of  the  Original  Tumor  of  Which  the  Tumors  Shown  in 
Fig.  242  are  Metastases. 


evident.  Metastases  do  not  form  early,  and  it  takes  a  long  time 
for  the  growth  to  extend  below  the  skin.  Therefore,  in  most  cases 
the  removal  of  an  elliptical  piece  of  skin  containing  the  nicer  will 
give  a  permanent  cure.  (For  the  details  of  such  an  operation  see 
Chapter  XX.) 

In  giving  a  prognosis  it  is  well  to  remember  that  any  other 
scaly  patch  may  undergo  similar  degeneration,  so  that  this  risk 
must  be  added  to  the  slight  risk  of  a  recurrence  after  ex- 
cision. 

Carcinoma  in  the  hand — a  metastatic  tumor  from  carcinoma 
in  some  other  part  of  the  body — is  a  rarer  form  of  malignant 
growth.  Such  a  case  is  shown  in  Figure  242,  and  the  original 
tumor  in  Figure  243.     There  is,  of  course,  no  treatment  for  such 


462    TUMORS  AND  DEFORMITIES   OF   THE  ARM   AND   HAND 

metastatic  tumors,  unless  pain  or  ulceration  should  make  amputa- 
tion desirable.  Usually  these  symptoms  are  obscured  by  the  move 
serious  symptoms  of  the  primary  growth  or  metastatic  tumors  in 
more  vita]  parts  of  the  body. 

Sarcoma. — A  sarcoma  is  a  connective  tissue  tumor,  and  is 
therefore  found  in  every  part  of  the  body.  In  the  upper  extrem- 
ity it  Usually  originates  in  the  skin  or  in  one  of  the  bones.  In  the 
former  situation  (  Fig.  244),  it  must  be  differentiated  from  fibroma 
mid  fibrolipoma,  and  also  from  the  lesions  of  syphilis  and  tuber- 


FiG.  244. — Tumor  of  Hand,  Said  to  Have  Existed  Ten  Years.  The  lesion  was 
considered  tuberculous,  until  the  pathologist  pronounced  it  spindle-celled  sar- 
coma.    The  patient  was  a  man  aged  thirty  years. 

culosis.  Sarcoma  of  a  bone  may  be  mistaken  for  osteoma  or 
enchondroma,  and  also  for  the  lesions  of  tuberculosis  and  syphilis. 
It  is  true  that  mistakes  in  diagnosis  are  most  likely  to  be  made 
at  an  early  stage  of  the  growth,  but  it  is  just  at  that  time  that  a 
complete  removal  of  the  growth  is  possible;  therefore,  an  early 
exact  diagnosis  is  most  important.  If  this  cannot  be  made  certain 
in  any  other  way,  a  section  of  the  growth  should  be  removed  for 
microscopical  examination. 

The  only  treatment  for  a  patient  with  sarcoma  of  the  upper 
extremity  is  thorough  removal  of  the  tumor  and  the  tissue  from 
which  it  springs,  even  though  an  amputation  of  hand  or  arm  be 


CICATRICIAL   CONTRACTIONS  403 

necessary  to  accomplish  this  object.     (For  minor  amputations  see 
p.  390.) 

An  operator  is  placed  in  a  trying  situation  if  he  Cuts  into  a 
; ■upposedly  benign  growth,  and  finds  from  its  appearance  that  it 
is  probably  a  sarcoma.  If  it  can  be  freely  removed  without  the 
sacrifice  of  important  structures,  this  is  evidently  the  course  to 
pursue.  Usually  the  case  will  stand  thus:  The  appearance  of  the 
tumor  indicates  malignancy,  and  yet  a  microscopical  examination 
is  necessary  to  determine  this  fact  with  certainty;  the  tumor  is 
so  situated  that  to  cut  wide  of  its  margin  will  destroy  some  im- 
portant structures.  Under  such  circumstances  the  surgeon  should 
remove  a  section  of  the  growth  for  examination  and  close  the 
wound,  stating  the  case  frankly  to  the  patient.  After  the  mi- 
croscopic examination  has  been  made  the  appropriate  opera- 
tion can  be  performed.  This  plan  is  far  better  than  an  im- 
perfect removal  of  a  sarcoma:  for  once  the  visible  tumor  is 
removed,  the  patient  will  almost  certainly  forbid  a  second 
operation  in  the  hope  that  all  of  the  tumor  has  been  removed, 
and  consent  will  not  again  be  obtained  until  the  tumor  is  pal- 
pably returning.  In  this  way  valuable  time  is  lost,  and  the 
chance  of  radical  removal  lessened.  The  effect  on  the  patient's 
mind  is  quite  different  when  the  surgeon  explains  to  him  be- 
fore the  first  operation  the  possibility  of  malignancy  and  a  sec- 
ond operation  (see  p.  453). 

ACQUIRED   DEFORMITIES 

Cicatricial  Contractions. — The  usefulness  and  beauty  of 
the  hand  is  greatly  impaired  by  the  cicatricial  contractions  follow- 
ing burns  and  severe  inflammations  (Fig.  245).  (See  also  Figs. 
206  and  207,  pp.  421  and  422.)  If  the  damage  is  done  in  infancy, 
the  deformity  may  actually  increase  with  the  growth  of  the  parts. 
Hence  the  desirability  of  performing  what  restoration  is  possible 
before  the  fingers  develop  along  abnormal  lines.  In  many  cases 
no  treatment  is  indicated;  in  others  plastic  operations  or  skin- 
grafting  may  give  a  greater  range  of  motion,  or  improve  the 
position  of  the  parts.  In  such  cases  there  will  always  be  a  par- 
tial recurrence  of  the  deformity,  due  to  contraction  of  the  new 
formed  scar  tissue. 


464    TUMORS    AND   DEFORMITIES   OF   THE   ARM   AND   HAND 

A  certain   amount   of  contract  ion   also  follows  the  successful 
application  of  a  Thiersch  graft.     Therefore  if  the  raw  surface 


Fig.  245. — Cicatricial,  Contractions  from  Burns  in  Infancy. 

which  follows  the  dissection  of  the  cicatrix  cannot  he  covered  by 
an  attached  flap  of  skin,  a  Wolfe  graft  should  he  employed. 
It  will  often  be  necessary  to  lengthen   the   tendons  in  order  to 


Fig.  246. — Diagram  to  Show  a  Quick  Method  of  Lengthening  a  Tendon 
Without  Suture  When  the  Tendon  is  of  Sufficient  Size. 


DUPUYTREN'S  CONTRACTION 


465 


obtain  complete  extension.  This  can  be  quickly  accomplished 
without  the  use  of  sutures  by  making  two  overlapping  L-shaped 
incisions  in  each  tendon  (Fig.  246).  Or  the  tendon  may  be 
divided  obliquely  and  sutured. 

One  should  be  careful  not  to  sacrifice  strength,  simply  to  gain 
a  wider  range  of  motion.  A  badly  displaced  useless  finger  is  often 
justly  amputated. 

Dupuytren's  Contraction.  — This  is  a  contraction  of  the 
palmar  fascia,  which  comes  on  gradually  in  persons  who  work 
hard  with  the  handle  of  an  instrument 
in  the  palm.  The  fascia  is  thickened 
and  drawn  into  distinct  bands,  which 
seem  like  cords  extending  to  the  various 
lingers,  especially  to  the  ring  and  little 
fingers.  Complete  extension  of  the  fin- 
gers is  then  impossible  (Fig.  247).  The 
skin  is  puckered  in  places  by  the  traction 
upon  it  from  the  contracted  fascia. 

The  only  satisfactory  treatment  of 
this  trouble  is  the  removal  of  the  thick- 
ened fascia  after  its  dissection  from  the 
skin,  and  the  underlying  structures. 
When  the  fascia  is  removed,  the  fingers 
can  be  extended.  There  is  some  tend- 
ency to  recurrence  of  the  condition,  but 
in  a  less  marked  form,  so  that  operation 
is  amply  justified.  It  is  performed  as 
follows:  After  local  or  general  anesthe- 
longitudinal 


Fig.  247. — Duputtuen's  Con- 
traction of  Six  Months' 
Duration.  Maximum  pos- 
sible extension  of  fingers 
shown.  Note  the  pucker- 
ing of  the  skin,  where  it  is 
adherent  to  the  thickened 
fascia. 


sia,  a  longitudinal  incision  is  made 
through  the  skin  of  the  palm  at  the  site 
of  the  greatest  contraction.  It  should 
usually  be  from  two  to  three  inches  long. 
The  skin  is  divided  as  deep  as  the  fascia, 
and  the  two  skin  edges  are  dissected 
away  from  the  contracted  fascia  for  about  an  inch  on  either  side. 
This  is  the  essential  part  of  the  operation.  Care  should  be  taken  to 
keep  these  skin  flaps  thick  so  they  will  not  slough.  Next  the  thick- 
ened and  contracted  fascia  is  divided,  dissected  from  the  deeper 
structures  to  which  it  is  attached  by  numerous  septa,  and  removed. 


466     TUMORS   AND  DEFORMITIES   OF   THE  ARM   AND   HAND 

The  fascia  is  sometimes  thickened  into  cords  like  tendons,  so  that 
one  who  is  performing  (his  operation  for  the  first  time  may  hesi- 
tate to  ent  them.  There  are  two  unmistakable  differences.  The 
tendons  are  always  the  color  of  ivory;  the  fascia  is  pearly  white. 
The  tendons  never  lie  immediately  beneath  the  skin  as  the  fascia 
does.  After  removal  of  the  fascia  the  wound  should  be  sutured 
and  the  hand  kept  on  a  splint  fully  extended  for  several  weeks. 
Active  and  passive  motions  should  be  made  as  soon  as  the  wound 
has  healed,  but  to  prevent  return  of  the  contraction,  full  extension 
on  a  splint  should  be  kept  up  a  part  of  each  day  or  at  night  for 
several  weeks. 

In  slight  cases  multiple  Y-shaped  incisions  with  forced  ex- 
tension will  accomplish  something,  but  this  treatment  is  gen- 
erally unsatisfactory  on  account  of  the  intimate  attachment 
of  the  skin  and  fascia. 


Fig    248. — Radiograph  of  the  Hand  of  an  Infant,  All,  the   Bones  Normal, 
and  All  the  Fingers  Webbed      The  other  hand  was  perfect. 


WEB-FINdER 


467 


CONGENITAL   DEFORMITIES 


There  are  four  types  of 
congenital  deformity  seen 
in  the  upper  extremity, 
viz.,  web-finger,  supernu- 
merary finger,  hypertro- 
phy, and  deficiency  of  one 
or  more  fingers,  or  some 
greater  portion  of  the  hand 
or  arm. 

Web  -  Finger. — Web- 
finger  occurs  in  varying  de- 
grees. In  the  simple  cases 
there  is  merely  an  exten- 
sion of  the  normal  web  be- 
tween the  fingers,  all  of  the 


Fig.  250.- — Incision  and  Suture  for  Web- 
finger.  The  incisions  are  not  made  in  the 
best  situations.  One  should  be  more  pal- 
mar and  one  more  dorsal.  Same  subject 
as  Fig.  249. 
32 


Fig.  249. — The  Hand  of  Child 
Showing  Congenital  Deform- 
ity. One  finger  is  missing,  and 
the  other  is  represented  by  its 
distal  portion  only,  the  nail  and 
terminal  phalanx  of  which  are 
closely  joined  to  its  fellow. 
Drawn  from  a  photograph. 


bones  of  which  are  normal- 
ly formed  (Fig.  248).  In 
severer  cases  the  bones  lie 
much  closer  together,  or 
may  be  fused,  or  some  of 
the  bones  may  be  wanting 
(Fig.  2i9).  Web-fingers 
should  be  separated  early 
by  operation,  so  that  as 
growth  takes  place  the  fin- 


Ills    Tl  MORS  AND  DEFORMITIES   OF  THE  ARM   AND   HAND 

gers  may  develop  individually,  but  it  is  better  to  defer  operation 
till  the  child  is  a  year  old,  as  a  very  young  infant  does  not  stand 
well  the  loss  of  blood.  Operation  consists  in  I  ho  division  of  the 
skin  which  forms  the  web,  and  the  closure  of  the  wounds  on  each 
finger  by  suture  as  far  as  possible.  The  incisions  for  this  purpose 
should  not  be  exactly  opposite  as  they  were  in  the  case  shown  in 
Figure  250,  for  the  web  will  then  partly  recur  by  granulation  of 
the  wounds  at  the  bottom  of  the  fingers.  A  better  plan  is  to 
make  the  incision  on  one  finger  ventral,  and  on  the  other  finger 
dorsal. 

During  recovery  from  the  operation  care  should  be  taken  to 
keep  the  fingers  as  widely  separated  as  possible,  and  their  active 
use  should  be  encouraged  as  soon  as  the  skin  has  united. 

Supernumerary  Finger. — The  superfluous  member  may 
be  attached  to  the  normal  portion  by  skin  only,  or  by  its  bony 


A>  ' 

M'  B 

■■-■  m^/j 

•^^JL_ 

Fig.  251. — Supernumerary  Thumb  Springing  from  the  First  Phalanx  of  the 
Normal  Thumb,  Without  Articulation. 

structure.  In  the  latter  case,  there  may  be  an  articulation  or  the 
bone  of  the  superfluous  finger  may  spring  direct  from  a  normal 
shaft  (Figs.  251  and  252). 

A  supernumerary  finger  or  thumb  should  be  removed.  Even 
if  the  extra  member  is  articulated  with  the  hand,  its  possible  use 
in  no  wise  compensates  to  the  individual  for  the  unpleasantness 


TOO   MANY  ACCESSORY  TENDONS  400 

of  such  an  abnormality.  If  the  attachment  is  of  skin  only.,  this 
should  be  divided.  If  there  is  an  articulation,  the  line  of  separa- 
tion should  pass  through  it.     If  the  attachment  is  a  bony  one, 


Fig.  252. — Radiograph  of  Supernumerary  Thumb.  Note  how  the  phalanx  has 
developed  abnormally.  Operation  in  infancy  would  have  prevented  this.  Same 
subject  as  Fig.  251. 

enough  bone  should  be  cut  away  to  restore  the  normal  contour 
of  the  bone  from  which  the  supernumerary  finger  springs.  In 
all  cases  care  should  be  taken  to  leave  sufficient  skin  to  cover  the 
wound  readily.  These  operations  should  be  performed  in  infancy. 
The  loss  of  blood  is  extremely  slight  so  that  they  need  not  be 
deferred  until  the  child  is  a  year  old. 

Congenital  Hypertrophy  and  Congenital  Deficiency 
of  one  or  more  fingers  are  conditions  in  which  surgical  interfer- 
ence is  usually  not  indicated.  Amputation  of  a  part  of  a  hyper- 
trophied  finger,  or  of  a  useless  undeveloped  finger,  needs  no  fur- 
ther explanation  than  that  given  for  amputation  of  a  finger  on 
page  390. 

Too  Many  Accessory  Tendons. — The  accessory  tendons 
on  the  back  of  the  hand,  the  vinculse  which  bind  the  extensor  ten- 


170      TUMORS   AND   DEFORMITIES   OF   THE   ARM    AND    HAND 

dons  together  and  add  to  the  strength  of  the  hand  when  used  as 
a  whole,  greatly  impede  the  action  of  the  individual  fingers.  For 
some  occupations  and  in  some  persons  they  may  fairly  be  considered 
congenita]  deformities.  The  ring-finger  (fourth  digit)  suffers  the 
most,  as  its  extensor  tendon  often  has  branches  extending  to  those 
of  the  middle  and  little  fingers.  Full  extension  of  the  fourth  digit 
is  then  impossible  unless  the  third  and  fifth  are  at  least  partially 
extended.  This  is  ;i  distinct  disadvantage  for  one  who  would 
play  the  piano  or  violin,  and  pupils  ol'ien  spend  many  weary  hours 
Irving  to  increase  the  range  of  motion  of  the  affected  finger. 
Some  gain  in  motion  may  follow  such  practise,  especially  at  an 
early  age,  hut  a  far  better  plan  is  the  removal  through  a  short 
incision  of  the  limiting  accessory  tendons.  This  slight  operation 
will  at  once  greatly  increase  the  range  of  extension  of  the  linger 
which  is  freed  and  will  not  materially  weaken  I  he  hand.  The 
operation  is  performed  as  follows: 

Alter  preparation  of  the  skin  and  injection  of  cocain,  a  longi- 
tudinal incision  should  he  made  through  the  skin  directly  over 
the  accessory  tendon  to  be  removed.  Its  sheath  should  be  exposed 
and  opened,  and  at  least  an  inch  of  the  accessory  tendon  should  be 
resected,  so  that  it  may  be  cut  off  flush  with  the  sheath  of  the  main 
tendon.  The  sheath  of  the  accessory  tendon  should  also  be  resected 
and  the  cut  ends  closed,  each  by  a  stitch  or  two  of  fine  catgut. 
The  skin  wound  should  be  closed  by  interrupted  sutures  or  a  sub- 
cuticular one  (p.  573),  and  a  dry  gauze  dressing  applied.  The 
stitches  should  be  removed  in  five  day-. 

The  resection  of  the  accessory  tendon  sheath,  and  the  closure 
of  its  cut  ends,  is  to  prevent  the  reformation  of  the  accessory 
tendon.  Even  if  this  does  take  place  it  is  several  weeks  before 
the  new  tendon  becomes  firm,  and  during  this  period  the  patient 
has  an  opportunity  to  extend  the  finger  in  question  to  a  far  greater 
extent  than  formerly.  The  gain  thus  made  will  be  largely  per- 
manent. Exercises  should  be  begun  a  few  days  after  the  wound  in 
the  skin  has  united — say  in  ten  days. 


SECTION   VII 
AFFECTIONS  OF  THE  LEO  AND  FOOT 


CHAPTER    XVII 
INJURIES    OF    THE    LEG    AND    FOOT 

Contusions  and  Abrasions. — Contusions  and  abrasions  of 
the  lower  extremity  are  perhaps  oftenest  found  upon  the  shin. 
The  circulation  of  blood  is  less  active  in  the  leg  and  foot  than  in 
any  other  part  of  the  body ;  hence,  wounds  do  not  heal  as  readily 
in  these  parts,  and  bruises  or  slight  breaks  in  the  skin,  trivial  in 
themselves,  may  become  starting-points  for  serious  inflammations. 
Therefore,  every  injury  of  the  lower  extremity  should  receive 
prompt  and  efficient  treatment.  If  it  is  situated  below  the  knee, 
the  skin  should  be  carefully  cleansed,  and  a  dry  gauze  dressing  or 
a  moist  antiseptic  dressing  should  be  applied  to  it,  and  the  limb 
bandaged  from  the  toes  to  the  knee,  at  least  until  repair  is  well 
started.  As  the  heel  never  swrells  much,  it  should  be  left  bare, 
unless  it  is  wounded.  Such  a  bandage  will  prevent  edema  and 
facilitate  the  circulation  of  the  blood  in  the  limb.  Above  the  knee 
the  circulation  is  better,  and  repair  takes  place  more  rapidly. 

Blister. — Unaccustomed  exercise  and  ill  fitting  shoes  are  re- 
sponsible for  most  of  the  blisters  which  develop  on  the  foot,  usually 
on  the  heel  and  toes.  They  may  contain  clear  serum  or  bloody 
serum.  Often  they  have  been  broken  accidentally  or  intentionally 
before  the  doctor  sees  them.  The  fluid  should  be  evacuated  from 
the  others  by  the  passage  of  a  sterile  needle  obliquely  through  the 
sound  skin  at  the  edge  of  the  blister.  Cleanliness  should  be  ex- 
treme in  order  to  avoid  infection.  Tender  and  abraded  surfaces 
should  be  treated  by  cold  cream,  or  by  a  moist  antiseptic  dressing, 
according  to  the  severity  of  the  lesion.  Cold  bathing  and  rubbing 
the  sound  skin  with  alcohol  will  toughen  it  and  render  less  likely 

the  formation  of  blisters. 

471 


Fig.  253. — Hematoma  of  Foot  Produced  by  a  Slight  Turn  of  the  Ankle     Pho- 
tograph six  hours  after  the  accident. 


Fig.  254. — Hematoma  Under  Left  Great  Toe-nail.     Note  the  elevation  of  the  nail 
beneath  the  skin  as  far  as  its  matrix. 
472 


HEMATOMA 


473 


Hematoma. — For  the  diagnosis  of  a  hematoma  the  reader  is 
referred  to  page  2.  If  the  amount  of  effused  blood  in  a  hema- 
toma is  small  (Fig.  253),  it  may  safely  remain  undisturbed  for 
resorption.  If  the  quantity  of  blood  is  large,  it  should  be  removed 
through  a  longitudinal  incision,  and  the  wound  sutured.  If  the 
patient  is  first  seen  some  days  after  the  injury,  the  blood  clot  may 
have  softened  sufficiently  to  permit  its  extraction  through  a  large 
hollow  needle. 

Hematoma  under  a  toe-nail  (Fig.  254)  presents  the  same  symp- 
toms and  demands  the  same  treatment  as  hematoma  under  a  finger- 
nail (p.  325). 

Subperiosteal  hematoma  (Fig.  255)  is  less  easy  to  diagnose, 
since  it  may  exist  without  discoloration  of  the  skin.     It  is  usually 


Fig.  255. — Subperiosteal  Hematoma  of  the  Head  of  the  Tibia;  Three  Weeks 
Old  from  Traumatism.  The  joint  was  not  involved  and  contained  no  fluid. 
Patient  a  man  aged  forty  years. 


due  to  a  direct  blow.  It  gives  a  tense,  rounded,  fluctuating,  ten- 
der swelling,  immovable  on  the  bone,  and  covered  by  movable  skin. 
It  must  be  differentiated  from  a  contusion  of  periosteum   (less 


474  INJURIES   OF  THE   LEG   AND   FOOT 

.-welling  and  no  fluctuation)  ;  from  a  serous  effusion  under  the 
periosteum  (differenl  fluid  on  aspiration)  ;  from  a  subperiosteal 
abscess  (greater  tenderness,  edema  of  surrounding  tissues,  fever, 
etc.);  from  a  fracture  (usual  signs,  especially  pain  on  pressure 
made  on  the  two  ends  of  the  bone,  radiograph);  from  syphilitic 
gumma;  from  tuberculous  osteitis,  and  from  sarcoma.  The  three 
last  mentioned  lesions  develop  gradually,  and  often  -without  trau- 
matism. Under  certain  circumstances  fluctuation  is  present  in  all 
throe,  but  the  fluid,  if  aspirated,  will  be,  in  the  case  of  gumma,  a 
straw  m-  orange  colored  thin  sirup;  in  tuberculous  osteitis,  a  thin, 
flaky  pus;  and  in  sarcoma,  pure  fresh  blood;  while  the  tluid  from 
a  hematoma  is  dark,  abnormal  blood.  The  radiographs  of  the  three 
lesions  are  also  different,  and  a  gumma  will  often  diminish  very 
much  in  size  after  a  few  days'  treatment  with  potassium  iodid. 
The  treatment  of  hematoma  is  given  above.  After  either  aspira- 
tion or  incision  a  firm  bandage  should  be  applied  to  prevent  recur- 
rence. 

Rupture  of  a  Vein. — Rupture  of  a  vein  of  the  leg  may 
be  followed  by  a  serious  loss  of  blood.  The  vein  which  bursts 
is  always  varicose,  and  the  overlying  skin  is  much  atrophied  on 
account  of  this  varicosity.  A  previous  ulceration  and  cicatrization 
may  also  be  present,  though  this  is  not  necessary.  The  rupture 
of  the  vein  usually  follows  some  slight  traumatism.  The  opening 
is  small,  and  light  pressure  applied  directly  to  it  readily  controls 
the  bleeding.  The  wound  should  be  cleansed  (p.  13)  and  a 
sterile  gauze  compress  bandaged  over  it  and  left  in  place  for  a 
few  davs.  Ligation  of  the  vessel  is  not  often  called  for.  To 
perform  this  operation,  make  a  skin  incision  parallel  to  the  vein, 
free  the  vessel  for  a  half  inch  or  more,  pass  a  double  catgut  liga- 
ture about  it,  tie  it  above  and  below  the  rupture,  and  then  cut 
the  vein  in  two.  Suture  the  incision  in  the  skin  and  apply  a  dry 
dressing. 

Subcutaneous  rupture  of  a  vein  also  occurs,  due  either  to  direct 
violence  or  to  indirect  violence.  When  it  is  due  to  a  sudden 
strain  or  to  a  fall,  the  presence  of  effused  blood  may  lead  to  a 
false  diagnosis  of  fracture.  For  the  treatment  of  the  resulting 
hematoma  see  page  3.  Tf  hemorrhage  continues  in  spite  of  pres- 
sure, a  free  incision  should  be  made  and  the  bleeding  vessel  exposed 
and  ligated.     The  wound  should  be  sutured. 


wounds  475 

Rupture  of  Tendon. — The  slender  tendon  of  the  plantaris 
muscle  sometimes  snaps  as  the  result  of  sudden  tension.  This  acci- 
dent causes  a  sharp  pain  in  the  back  of  the  leg,  as  if  a  smart  blow 
were  given  with  a  stick.  Soreness  and  lameness  follow,  lasting  a 
few  days.  There  may  or  may  not  be  a  slight  ecchymosis  appear- 
ing on  the  surface  after  a  few  days.  The  only  treatment  required 
is  warm  bathing  and  rubbing,  to  overcome  the  soreness.  The 
accident  is  not  a  common  one. 

Wounds.- — While  there  is  nothing  peculiar  in  the  diagnosis 
of  wounds  of  the  lower  extremity,  it  is  desirable  to  emphasize  the 
importance  of  thorough  treatment  of  even  trivial  wounds  when 
they  occur  in  the  aged  or  others  whose  circulation  is  not  the  best. 
Many  intractable  ulcers  of  the  leg  and  serious  infections  of  the 
foot  start  in  wounds  which  would  have  healed  promptly  had  ra- 
tional treatment  been  given  them.  An  old  physician  once  said  to 
the  author :  "  No  man  ever  performed  an  operation  for  cataract 
more  carefully  than  I  cut  my  corns."  He  was  a  diabetic,  and  had 
good  reason  to  be  careful ;  but  infection  and  ulceration  follows  care- 
lessly treated  wounds  of  the  foot  and  leg  in  many  persons  whose 
resistance  has  been  decreased  by  nephritis,  heart  disease,  anemia, 
repeated  childbirth,  and  other  causes. 

Three  common  illustrations  of  the  serious  trouble  which  may 
develop  from  infected  wounds  are :  Ulcer  of  the  leg  from  a  wound 
of  the  shin ;  suppuration  in  the  first  metatarsophalangeal  joint 
from  a  wound  of  the  overlying  bursa ;  perforating  ulcer  of  the 
foot  from  a  wound  by  the  side  of  a  callus  of  the  sole  of  the  foot. 

Punctured  Wound  of  a  Joint. — There  are  a  few  special  struc- 
tures which  may  be  injured  in  wounds  of  the  lower  extremity. 
The  knee-joint  may  be  opened  by  a  wound  at  either  side  of  the 
patella,  or  either  side  of  the  quadriceps  tendon ;  the  ankle-joint 
may  be  opened  by  a  wound  behind,  below,  or  in  front  of  either 
malleolus ;  the  first  and  fifth  metatarsophalangeal  joints  may  be 
opened  by  wounds  at  the  side  of  the  respective  joints.  If  the 
wound  of  a  joint  is  small  and  made  by  a  clean  instrument,  the 
only  symptom  may  be  the  escape  of  viscid  fluid.  In  most  cases 
there  will  be,  however,  some  signs  of  irritation,  such  as  swelling 
of  the  joint,  increased  fluid  in  it,  tenderness  on  manipulation,  and 
a  limitation  of  motion  on  account  of  pain.  If  the  infection  is 
severe,  there  will  be  great  edema  and  pain,  high  fever,  chills,  etc. 


476  INJURIES   OF  THE   LEG   AND    FOOT 

In  ilic  usual  ca.-c,  if  the  wound  is  recent,  it  should  be  explored 
up  !<»  the  joint  capsule.  If  there  is  reason  to  believe  that  the  joint 
has  not  been  infected,  a  drain  should  he  so  placed  as  just  to  reach 
tin-  capsule  of  the  joint,  and  the  superficial  wound  should  be  closed. 
If  there  is  reason  to  suppose  that  foreign  material  has  been  car- 
ried into  the.  joint,  or  if  infection  is  already  present,  the  joint 
should  be  irrigated  and  drained  through  a  second  incision,  if 
necessary.      (  See  p.    ">32.  ) 

Division  of  Tendons  or  Nerves. — Every  wound  should  be  ex- 
plored for  the  sake  of  cleanliness  and  for  the  suture  of  tendons 
and  nerves  which  may  have  been  divided.  This  complication  is 
most  likely  to  follow  wounds  behind  a  malleolus  or  at  the  front  of 
the  ankle.  The  directions  for  suturing  a  divided  tendon  and  nerve 
are  given  on  pages  332  and  334. 

Bursitis. — There  are  numerous  bursa?  in  the  lower  extremity. 
More  than  twenty  are  described  in  the  vicinity  of  the  knee-joint, 
but  most  of  them  perform  their  function  so  perfectly  that  they 
never  come  to  the  notice  of  patient  or  surgeon.  Of  all  the  bursae 
of  the  lower  extremity,  the  prepatellar  bursa  is  most  often  affected, 
and  on  this  account,  and  because  its  reactions  are  typical,  its 
lesions  will  be  first  described. 

Acute  Prepatellar  Bursitis. — This  affection  is  often  seen  in 
persons  who  work  on  their  knees,  scrubbing  floors,  laying  carpets, 
etc.,  but  is  by  no  means  confined  to  them.  While  it  is  true  that 
a  person  kneels  on  the  tubercle  of  the  tibia  rather  than  on  the 
patella,  yet  the  latter  is  constantly  bruised  and  strained  in  reaching 
or  crawling  forward.  The  knee  of  a  woman  who  scrubs  for  a 
living  shows  two  calluses,  one  over  the  tibial  tubercle  and  one  at 
the  lower  margin  of  the  patella,  unless  these  two  are  fused  in  one 
large  callus. 

If  the  prepatellar  bursa  is  distended  with  fluid,  serum,  or  pus 
or  blood,  it  plainly  fluctuates.  Sometimes  the  bursa  is  situated 
directly  in  front  of  the  patella,  but  usually  it  covers  only  the  lower 
half  of  this  bone,  and  may  extend  over  a  part  of  the  patellar 
ligament.  Such  variations  in  situation  have  no  surgical  impor- 
tance. It  is  of  the  greatest  importance  to  distinguish  fluid  in  the 
prepatellar  bursa  from  fluid  in  the  pretibial  bursa,  situated  behind 
the  patellar  ligament,  and  from  fluid  in  the  knee-joint  itself.  It  is 
easy  to  do  this  if  the  patient,  lying  or  sitting,  is  able  to  extend 


BURSITIS 


477 


the  leg  horizontally.  The  increased  tension  of  the  patellar  liga- 
ment will  obscure  fluctuation  within  the  area  covered  by  the 
ligament,  provided  that  the  fluid  lies  behind  it,  although  fluc- 
tuation at  the  sides  may  be  made  more  distinct  thereby.  If  the 
fluid  lies  in  front  of  the  ligament  or  patella,  fluctuation  will 
not  be  affected  by  extension  of  the  leg.  The  fat  behind  the  patel- 
lar ligament  being 
more  or  less  con- 
fined, often  fluctu- 
ates. If  edema  is 
present,  the  result 
of  trauma,  com- 
parison of  the  two 
knees  may  fail  to. 
clear  the  diagno- 
sis. A  few  days' 
rest  will  reduce  a 
swelling  due  to  a 
traumatic  edema, 
but  will  not  cause 
the  disappearance 
of  a  bursitis. 

The  physical 
signs  of  bursitis 
are  these :  A  well 
localized  fluctuat- 
ing swelling  cov- 
ered by  movable 
normal  skin;  only 
slight  tenderness 
and  pain;  little  disturbance  of  the  functions  of  the  adjacent  joint 
(Fig.  256). 

Suppurative  Prepatellar  Bursitis. — If  the  bursa  is  infected,  the 
contained  fluid  will  be  purulent ;  there  will  then  be  edema  and  red- 
ness of  the  tissues  outside  of  the  bursa,  and  pain  and  tenderness 
and  impairment  of  function  will  be  proportionately  greater.  The 
lesion  must  then  be  differentiated  from  an  abscess  in  the  subcuta- 
neous tissues  outside  the  bursa.  In  this  case  the  swelling  will  not 
be  so  sharply  limited,  and  will  probably  not  correspond  so  exactly 


Fig.  256. — Prepatellar  Bursitis. 


47cS 


J.\.M  l;ii:s    OF   THE    LKti    AM)    I"<  >(  >T 


to  the  situation  of  the  bursa.  For  example,  an  abscess  in  the  front 
of  the  kntv  will  probably  lie  more  to  one  side  than  the  other, 
whereas  swelling  due  to  suppuration  in  the  prepatellar  bursa  "will 
extend  equally  toward  both  sides.  It  is  of  course  possible  for 
suppuration  in  a  bursa  to  break  through  the  sac  and  extend  into  the 

subcutaneous  tis- 
sue. In  the  case 
of  the  prepatellar 
bursa,  such  rup- 
ture is  usually 
through  the  skin 
(  Fig.  257). 

Chronic  Prepa- 
tellar     Bursitis 

The  acute  bursitis 
may  subside,  the 
fluid  being  ab- 
sorbed. Usually 
the  sac  is  slightly 
thicker  than  be- 
fore. With  re- 
peated trauma- 
tisms, and  reaccu- 
mulations  of  fluid, 
this  organization 
<  »f  fibrous  tissue 
inside  the  sac 
may  go  on  until 
its  cavity  is  near- 
ly or  quite  oblit- 
erated, and  a 
slightly  elastic 
fibrous  tumor  occupies  the  site  of  the  bursa.  Such  a  tumor 
is  usually  painless,  but  gives  a  permanent  disfigurement.  Fig- 
ure 258  shows  a  bursa  in  process  of  organization,  removed  by 
operation,  and  split  open.  Numerous  buds  of  granulation  are 
seen,  one  of  which,  lying  across  the  blades  of  the  forceps,  is 
almost  long  enough  to  attach  itself  to  the  opposite  wall.  Two 
other  processes,   one   slender   and  one  thick,  both  of  which  are 


Fig.  257. — Suppuration-  in  Prepatellar  Bursa;  Rup- 
ture Through  Skin  Five  Weeks  Before  Photo- 
graph; Repair  by  Granulation  Taking  Place  in 
Lower  Portion  of  Cavity.  Patient  a  man  aged 
seventy  years. 


BURSITIS 


479 


also  lying  on  the  blades  of  the  forceps,  have  already  become  so 

attache*!. 

Treatment,  of  Prepatellar  Bursitis. — If  there  is  uncom- 
plicated prepatellar  bursitis,  palliative  treatment  is  permissible. 
Limitation  of  motion 
by  a  bandage  or  a  pos- 
terior splint;  pressure 
upon  the  bursa  by  a 
bandage  or  adhesive 
strapping ;  moist  ap- 
plications or  an  ice- 
bag  to  relieve  pain; 
and  counter-irritants 
such  as  tincture  of  io- 
diii  or  guaiacol,  are 
suitable  remedies.  If 
the  fluid  does  not  di- 
minish in  amount,  it 
may  be  withdrawn  by 
aspiration,  and  the 
part  tightly  strapped 
with  adhesive  plaster; 
or  twenty  minims  of 
a  mixture  of  equal  parts  of  carbolic  acid  and  camphor  may  be 
injected  into  the  bursal  sac.  This  will  sometimes  cause  the 
disappearance  of  the  fluid,  even  without  aspiration.  As  it  can 
be  injected  through  a  small  hypodermic  needle,  it  is  a  less  for- 
midable procedure  than  aspiration,  which  to  be  thorough  requires 
a  good  sized  needle.  Treatment  by  injection,  if  successful,  leaves 
a  thickened  bursa. 

If  the  bursa  is  infected,  it  should  be  split  longitudinally 
throughout  its  whole  extent.  This  may  be  done  under  cocain  or 
nitrous  monoxid.  The  cavity  should  be  lightly  filled  with  gauze, 
which  should  remain  for  several  days  to  favor  granulations  from 
the  whole  of  the  lining  of  the  bursal  sac.  When  this  has  been 
accomplished,  the  gauze  may  be  removed,  and  the  skin  edges  gradu- 
ally brought  together  by  strips  of  adhesive  plaster,  space  being  left 
between  them  for  drainage.  In  certain  cases  a  secondary  suture 
of  the  skin  is  advisable. 


Fig.  258. — Proliferative  Prepatellar  Bursitis. 
Bursa  removed  by  operation  and  split  open. 
Note  the  granulating  processes  of  various  lengths, 
some  of  which  have  already  become  attached  at 
both  ends.  Said  by  the  pathologist  to  be  tuber- 
cular.    Same  patient  as  Fig.  256. 


480 


JN.Il  i;ii:s   OF   THE   LEG   AND   FOOT 


The  best  treatment  for  chronic  serous  or  fibrinous  bursitis  is 
dissection  of  the  bursa  (Fig.  259)  and  suture  of  the  skiu.  This 
operation  demands  a  general  anc-tliciie  in  most  cases.  It  is  easy 
to  free  the  anterior  surface  and  sides  of  the  prepatellar  bursa  with 
the  help  of  a  local  anesthetic,  but  its  base  is  very  adherent  to  the 


Fig.  259. — Dissection  of  Prepatellar  Bursa,  Involved  in  Chronic  Inflamma- 
tion, in  this  Case  Pronounced  Tubercular  by  the  Pathologist.  Same 
subject  as  shown  in  Fig.  256.     Drawn  from  a  photograph. 

patella  or  ligament,  and  the  pain  of  this  dissection  is  not  easily 
stilled  by  eucain  or  eoeain.  Another  reason  for  the  removal  of  a 
chronically  involved  bursa  is  the  possibility  of  tuberculosis. 

Subgluteal  Bursitis. — One  of  the  bursas  in  the  vicinity  of  the 
hip  may  become  inflamed  as  the  result  of  traumatism  or  tubercu- 
losis. The  bursa  most  often  so  involved  is  situated  beneath  the 
gluteus  maximus  muscle.  It  gives  a  slight  oval  swelling  with 
a  little  tenderness  and  limitation  of  the  motions  of  the  hip-joint. 
It  may  therefore  be  mistaken  for  hip-joint  disease ;  or,  as  stated 
above,  it  may  be  a  complication  of  hip  disease.  In  every  case, 
therefore,  of  bursitis  of  this  region,  even  if  it  follows  a  trauma- 
tism, it  is  well  to  bear  this  fact  in  mind. 


kTTRSITlS  481 

The  Bursa  Gastrocnemio-Semimembranosa. — There  are  other 
bursse  of  the  lower  extremity  which  become  enlarged  with  suffi- 
cient frequency  to  make  them  important.  One;  is  the  bursa  under 
the  tendon  of  the  semimembranosus.  When  distended,  a  part 
of  this  bursa  is  palpable  in  the  popliteal  space,  while  the  rest  of 
it  is  hidden  beneath  the  inner  hamstring  tendons.  A  mistake  in 
diagnosis  ought  not  to  occur.  A  popliteal  aneurism  occupies  the 
middle  of  the  popliteal  space  and  pulsates.  An  abscess  is  accom- 
panied by  the  acute  signs  of  inflammation,  which  are  lacking  in 
distention  of  this  bursa;  and  even  a  cold  abscess  will  be  accom- 
panied by  some  local  tenderness  and  loss  of  function,  referable 
to  the  source  of  the  pus. 

The  only  treatment  worth  considering  is  the  removal  of  the 
bursa  by  dissection.  This  is  not  a  serious  operation,  but  it  de- 
mands a  general  anesthetic  and  several  days'  rest  in  bed.  In 
about  one  person  in  five  this  bursa  communicates  with  the  knee- 
joint,  a  fact  which  is  no  contra-indication  to  operation. 

The  Bursa  Under  the  Tendo  Achillis. — The  small  bursa  between 
the  tendo  Achillis  and  the  os  calcis  sometimes  becomes  inflamed 
as  a  result  of  excessive  exercise  or  a  fall  or  blow ;  or  the  trouble 
may  come  on  more  gradually,  as  a  complication  of  gout,  rheuma- 
tism, etc. 

The  chief  symptom  is  pain  at  the  back  of  the  heel,  so  that  the 
name  achillodynia  has  sometimes  been  applied  to  this  bursitis. 
The  pain  may  be  continuous,  or  it  may  be  excited  by  contraction 
of  the  muscles  of  the  calf  when  the  patient  bears  his  weight  upon 
the  ball  of  the  foot.  The  easiest  gait  under  the  circumstances  is 
to  rotate  the  leg  outward,  and  to  avoid  flexion  and  extension  of 
the  ankle. 

Treatment  consists  in  the  application  of  heat  and  counter-irri- 
tants ;  in  the  removal  of  pressure  by  splitting  the  heel  of  the  shoe 
or  wearing  a  slipper ;  in  disuse  of  the  foot  and  in  fixation  of  the 
ankle-joint  by  adhesive  strapping  or  in  more  severe  cases  by  the 
use  of  a  plaster  of  Paris  splint.  In  chronic  cases  complete  ex- 
cision of  the  bursa  is  indicated  through  two  short  incisions,  one 
on  either  side  of  the  tendo  Achillis.  A  plaster  of  Paris  splint 
should  be  applied  to  insure  recovery  with  the  foot  in  a  cor- 
rect position,  i.  e.,  flexed  at  least  to  a  right  angle  and  slightly 
inverted. 


482 


tNJURIES    OF   TIIF.    LEG    AND    FOOT 


Metatarsophalangeal  Bursitis;  Bunion.  A  bursa  lying  between 
the  skin  and  the  bead  "I'  the  firs!  metatarsal  bone  is  exposed  t<> 
pressure  from  a  shoe,  and  often  becomes  inflamed.  This  bursitis 
is  commonly  called  a  bunion,  although  this  term  is  used  to  indi- 
cate any  painful  swelling  about  this  metatarsophalangeal  joint. 
The  corresponding  bursa  of  the  fifth  metatarsal  bone  may  be  simi- 
larly affected  (Fig.  2G0). 

The  inflammation  in  the  bursa  may  subside,  leaving  its  walls 
slightly  thickened,  and  subjeel  in  a  recurrence  of  the  attack.     Or 


_ 

1 

V 

wL    s* 

BL  -•'  . ' 

IJn   '   drtflli        iiTrtrirfffl 

..^ 

Fig.  260. — Inflammation  of  the  Metatarsophalangeal  Bursa  on  the  Outer 

Side  of  the  Foot. 

if  the  inflammation  is  suppurative,  the  overlying  skin  may  rup- 
ture and  allow  the  escape  of  pus  and  mucus.  The  resulting  sinus 
may  heal,  or  it  may  persist,  or  it  may  close  from  time  to  time, 
only  to  break  open  as  the  fluid  reaccumulates  in  the  bursa.  As 
the  bursa  often  communicates  -with  the  metatarsophalangeal  joint, 
the  cavity  of  this  joint  frequently  becomes  involved  in  the  inflam- 
mation, which  may  lead  to  necrosis  of  the  metatarsal  bone.  This 
complication  is  most  apt  to  occur  in  cases  of  hallux  valgus. 
Indeed  this  bursa  is  rarely  inflamed  except  in  cases  of  hallux 
valgus. 


SEROUS   SYNOVITIS  483 

Treatment. — Mild  cases  of  bursitis  may  be  allowed  to  sub- 
side. The  affected  part  should  be  protected,  from  pressure  by  a 
bunion  plaster,  and  pain  should  be  controlled  by  counter-irritants, 
such  as  iodin,  guaiacol,  menthol,  etc.  Moist  and  dry  heat  both 
give  the  patient  great  relief. 

If  the  bursitis  is  suppurative  the  cavity  of  the  bursa  should 
be  freely  drained  by  a  longitudinal  incision  to  the  plantar  side 
of  the  bursa,  or  the  whole  bursa  may  be  removed,  by  dissection. 
In  either  case  the  wound  should  be  drained,  and  the  toe  kept  at 
rest  by  a  plantar  or  lateral  splint,  so  padded,  as  not  to  press  upon 
the  inflamed,  part  (Fig.  299,  p.  553).  If  the  joint  is  seriously 
involved,  resection  of  the  head,  of  the  metatarsal  bone  will  give 
the  best  drainage,  and  will  at  the  same  time  enable  the  surgeon 
to  correct  the  deformity  of  the  hallux  valgus  (see  p.  550). 

Serous  Synovitis. — The  majority  of  cases  of  serous  syno- 
vitis are  of  traumatic  origin,  and  are  discussed,  under  the  heading 
"  Sprain,"  pages  486-496,  where  methods  of  diagnosis  and.  treat- 
ment^ are  given.  Serous  synovitis  not  due  to  injury  occurs  in 
rheumatism  and  gonorrheal  arthritis,  though  the  process  in  these 
diseases  is  usually  an  arthritis,  all  of  the  tissues  which  surround,  the 
joint  being  involved.  It  also  occurs  in  acute  infectious  diseases,  and 
in  gout,  syphilis,  and  tuberculosis ;  and  occasionally  in  tabes  dor- 
salis  (Charcot's  joint),  and  under  some  circumstances  in  which  no 
definite  cause  can  be  assigned.  In  many  of  these  cases  the  collec- 
tion of  serum  in  the  cavity  of  the  joint  is  only  an  early  stage  of  an 
inflammation,  which  soon  becomes  purulent,  or  it  is  an  accompani- 
ment of  a  deeper  process,  as  in  tuberculosis,  tabes,  etc.  Hence 
every  effort  should  be  made  in  these  non-traumatic  cases  to  make 
a  complete  diagnosis,  and  not  to  rest  satisfied  with  the  diagnosis 
of  serous  synovitis.  The  location  of  the  fluid,  whether  in  the 
joint,  in  some  bursa,  or  diffuse  in  the  soft  tissues;  and  the  pres- 
ence of  accompanying  cellulitis  should  be  determined.  The 
amount  of  pain  on  manipulation,  and  especially  the  presence  of 
pain  produced  by  crowding  together  the  cartilaginous  ends  of  the 
bones,  without  flexing  or  extending  them,  is  of  importance  as 
showing  the  extent  to  which  inflammation  has  involved  the  bones. 
The  circumference  of  the  joint  and  of  the  limb  above  and  below 
it  should  be  compared  with  the  sound  limb  and  recorded  for  future 
reference.  Similar  note  should  be  made  of  the  limitation  of  flex- 
33 


|\1  INJURIES  OF  THE   LEG    AM)   FOOT 

i<>n  and  extension,  and  whatever  other  motion  the  joinl  lias  nor- 
mally. The  patient's  temperature  should  be  taken  several  times, 
for  h  day  or  so  at  least,  and  if  circumstances  permit,  the  blood 
should  be  examined,  and  fluid  aspirated  from  the  joint  should 
be  tested  for  bacteria.  Our  knowledge  of  joint  diseases  is  so 
imperfect  that  no  opportunity  should  be  lost  by  which  clinical 
data  may  be  added.  Finally,  there  is  the  test  of  treatment,  and 
especially  the  effect  of  rest,  and  of  the  salicylates  and  of  iodid  of 
potash. 

The  treatment  of  traumatic  synovitis  is  outlined  on  page  493. 
The  measures  there  indicated  are,  rest,  obtained  by  strapping  with 
adhesive  plaster  or  by  the  use  of  splints  or  by  remaining  in  bed; 
elastic  pressure  to  favor  the  resorption  of  the  fluid ;  ice  to  control 
pain ;  massage  or  counter-irritation  to  stimulate  circulation.  These 
measures  are  equally  beneficial  in  non-traumatic  serous  synovitis. 
Massage  and  passive  or  active  motion  should  not  be  employed  as 
long  as  an  active  inflammatory  focus  exists.  Aspiration  of  fluid 
has  a  curative  as  well  as  a  diagnostic  value.  In  sluggish  cases  it 
may  be  followed  by  the  injection  of  a  three  per  cent  solution  of 
carbolic  acid.  If  clots  or  fibrin  prevent  the  escape  of  the  joint 
contents,  saline  should  be  injected  and  withdrawn,  and  this  re- 
'  peated  until  the  joint  is  clean.  The  importance  of  absolute  asep- 
sis in  aspiration  or  irrigation  cannot  be  too  strongly  emphasized. 
Immediately  after  the  aspiration  pressure  should  be  applied  to 
the  joint. 

Chronic  Serous  Synovitis. — If  the  knee  or  ankle  is  subjected 
to  repeated  traumatisms,  the  condition  of  the  joint  may  become 
chronic.  It  is  then  desirable  to  use  counter-irritants  in  addi- 
tion to  the  measures  spoken  of  above.  The  actual  cautery  is 
one  of  the  cleanest  and  best.  Tincture  of  iodin,  iodin  ointment, 
and  cantharidal  collodion  are  other  efficacious  remedies.  The 
counter-irritation  should  be  repeated  in  three  days  or  one  week, 
according  to  depth  of  irritation  produced. 

Floating  Cartilage. — Patients  sometimes  complain  that  the 
knee  catches  in  walking,  or  in  going  up  or  down  stairs,  giving 
more  or  less  pain,  and  requiring  some  manipulation  before  it  will 
work  again.  Sometimes  a  clear  history  of  injury  is  given;  more 
often  this  is  not  the  case.  Such  mechanical  difficulty  may  be  due 
to  a  loose  cartilage  (Fig.  261),  a  body  found  only  in  the  knee- 


FLOATING  CARTILAGE 


485 


joint,  and  whose  origin  is  not  satisfactorily  accounted  for;  while 
sometimes  a  loosened  meniscus  plainly  slips  from  its  normal  situ- 
ation and  gets  caught  between  the  bones;  and  sometimes  one  can 
only  speculate  as  to  the  cause  of  the  trouble. 

A  joint  which  suffers  from  such  repeated  small  injuries  natu- 
rally becomes  weakened,  and  usually  contains  a  little  fluid.  If 
there  is  a  loose  cartilage, 
freely  movable  in  the  joint 
cavity,  one  cannot  hope  to 
improve  the  condition  of 
the  joint  until  it  is  re- 
moved. If  it  can  bo 
brought  well  to  one  side. 
and  fixed  by  a  hat-pin,  it 
can  be  removed  through  an 
incision  made  under  the 
influence  of  a  local  anes- 
thetic. This  should  not  be 
attempted  unless  it  is  rea- 
sonably certain  that  only 
one  such  loose  cartilage  ex- 
ists ;  and  the  asepsis  should 
be  absolute.  The  wound 
in  the  capsule  should  be 
sutured  with  fine  plain  cat- 
gut and  the  skin  wTound  sutured  with  fine  silk  and  a  dry  dressing 
and  posterior  splint  applied.  If  any  drain  is  employed,  it  should 
reach  only  to  the  incision  in  the  capsule,  and  should  be  removed 
in  two  days. 

While  in  removing  a  floating  cartilage  it  is  necessary  to  cut 
directly  down  upon  it,  there  is  often  a  choice  of  location,  since  it 
can  be  moved  about.  The  most  favorable  line  of  incision  is  that 
shown  in  Figure  262,  or  just  anterior  to  the  internal  lateral  liga- 
ment. At  this  point  the  capsule  of  the  joint  is  covered  only  by 
the  skin  with  its  fat  and  a  thin  fascia.  When  the  leg  is  extended 
this  incision  is  parallel  to  its  long  axis. 

These  are  the  simplest  cases.  If  more  than  one  loose  cartilage 
exists,  or  if  displacement  of  one  of  the  semilunar  cartilages  causes 
the  symptoms,  exploration  of  the  knee-joint  may  be  necessary,  and 


Fig.  261.  —  Floating  Cartilage  from  the 
Knee-joint:  the  "Joint  Mouse"  of  the 
Germans.  Removed  through  an  incision 
made  under  cocain  after  the  cartilage  was 
speared  with  a  hatpin.  The  illustration 
shows  the  cartilage  enlarged  1%  diameters. 


4Sf> 


INJURIES   OF    THE    LEG    AND    FOOT 


a  general  anesthetic  should  be  given.  The  exact  site  for  the  inei- 
sion  in  case  of  semilunar  displacement  may  sometimes  be  deter- 
mined by  palpation.  A  depression  can  sometimes  be  felt  where 
the  base  of  the  semilunar  has  become  loosened,  and  pressure  at 

this  point  causes  pain. 
Usually  it  is  the  ante- 
rior part  of  the  inner 
semilunar  which  is  af- 
fected. If  it  is  not 
deformed  or  broken,  it 
should  be  stitched  in 
correct  position  by  fine 
chromic  gut.  If  this  is 
not  feasible,  so  much  of 
the  cartilage  as  is  a  hin- 
drance to  free  motion  of 
the  joint  should  be  re- 
moved. 

The  incision  for  the 
removal  of  several  float- 
ing cartilages  from  the 
knee-joint  is  a  longitu- 
dinal one  slightly  longer 
than  the  one  shown  in 
Figure  262.  A  second 
incision,  opening  the 
outer  side  of  the  joint, 
is  rarely  necessary.  The 
capsule  of  the  joint 
should  be  sutured,  not 
too  tightly,  with  fine 
plain  catgut,  so  that  fluid  can  escape  if  it  accumulates.  A  drain 
should  lead  to  the  wound  in  the  capsule,  but  not  through  it,  and 
the  skin  should  be  sutured  with  silk  or  horsehair.  A  splint  should 
be  employed;  either  a  removable  posterior  one  or  a  circular  gyp- 
sum splint  with  a  fenestrum  to  permit  the  removal  of  the  drain 
in  two  days. 

Sprains. — In  injuries  of  this  sort  it  is  well  to  distinguish  as 
far  as  possible  between  overstretching,  or  even  rupture  of  the  liga- 


Fig.  262.  —  Incision  for  Removal  of  Floating 
Cartilage  from  the  Knee  Under  Local  An- 
esthesia. In  the  case  shown  the  cartilage  had 
been  chipped  from  the  tibia  by  traumatism, 
and  although  loose,  was  not  in  the  knee-joint. 
Its  approximate  shape  and  location  is  shown 
by  the  wad  of  adhesive  plaster,  the  upper  edge 
of  which  is  exactly  in  the  horizontal  plane  of 
the  knee-joint. 


SPRAIN  OF  THE   HIP  487 

inents,  and  contusions  of  the  soft  parts,  or  oven  of  the  bones  them- 
selves (see  p.  388). 

Sprain  of  the  Hip- joint. — The  hip-joint  is  so  well  surrounded 
with  strong  muscles  that  it  is  rarely  sprained.  Contusions  of  the 
hip  from  falls  on  the  side  are  common.  In  children  a  differential 
diagnosis  must  be  made  between  sprain  or  contusion  and  tubercu- 
losis of  the  joint;  in  adults  beyond  middle  age,  the  usual  differ- 
ential diagnosis  is  between  contusion  and  fracture  (possibly 
impacted)  of  the  neck  of  the  femur.  Age  is  not  an  absolute 
classifier  of  these  three,  so  that  all  should  be  considered  at 
any  age. 

Methods  of  Examination. — The  patient  should  be  stripped 
from  the  waist  down  and  placed  on  a  firm  level  surface.  A  folded 
towel  laid  between  the  thighs  and  brought  up  over  the  pubes  to  the 
umbilicus  in  no  way  interferes  with  a  complete  examination,  and 
by  lessening  very  much  the  feeling  of  exposure,  aids  the  patient 
in  relaxation.  The  hip  should  be  inspected  and  palpated,  and 
compared  with  the  opposite  side.  Any  change  in  color  or  outline, 
any  thickening  of  the  bones  about  the  trochanter,  any  points  of 
tenderness,  and  an  abnormal  position  of  either  limb  (abduction 
or  rotation),  should  be  carefully  noted. 

The  two  limbs  should  be  measured  from  the  anterior  superior 
iliac  spines  to  the  internal  or  external  malleoli.  Before  making 
these  measurements,  one  should  see  that  the  two  ilia  are  on  a 
level,  and  that  the  feet  and  legs  are  equally  distant  from  the 
median  line  of  the  body.  A  difference  in  length  of  less  than 
one-half  an  inch  has  little  diagnostic  value.  Fracture  of  the  neck 
of  the  femur  gives  a  shortening  of  an  inch  or  an  inch  and  one- 
half.  In  only  a  few  cases  is  it  more  or  less  than  these  amounts. 
In  sprain  and  the  early  stage  of  tuberculosis  there  is  no  short- 
ening if  the  limb  can  be  fully  extended.  If  measurements  reveal 
the  existence  of  shortening,  further  measurements  should  be  made 
to  determine  its  exact  location.  This  can  be  done  in  three  ways: 
(1)  The  tibiae  can  be  measured;  or  (2)  the  distance  from  the 
tip  of  the  great  trochanter  to  the  external  malleolus;  or  (3) 
Bryant's  perpendicular  laid  out.  To  do  this  accurately  one 
should  mark  the  upper  limit  of  the  great  trochanter  on  the  skin 
with  ink;  mark  the  anterior  superior  spine  in  the  same  way; 
and  then  draw  a  line  on  the  skin  directly  backward  (a  vertical 


48S  INJURIES   OF   THE    LEG    AND    FOOT 

line  as  the  patient  is  lying  horizontally),  and  let  fall  a  perpen- 
dicular from  the  trochanter  to  this  line  (Fig.  263).  A  difference 
in  these  two  perpendiculars  on  the  two  sides  will  indicate  a  dis- 
location of  the  femur,  a  fracture  of  the  neck,  or  an  error  of  meas- 
urement.    This  method  is  far  more  accurate  than  Nelaton's,  by 


Fig.  263. — Relations  of  the  Great  Trochanter  to  the  Ilium.     Bryant's  Per- 
pendicular is  the  Broken  Line. 

which  one  estimates  the  possible  displacement  of  the  trochanter 
by  drawing  a  line  on  the  surface  from  the  anterior  superior  spine 
to  the  ischium.  Such  a  line  is  a  curve,  more  markedly  so  in  stout 
persons,  and  it  is  difficult  to  be  sure  that  it  follows  the  same  course 
on  the  two  sides  of  the  body,  even  though  its  ends  are  accurately 
placed.  By  means  of  these  various  measurements  one  can  in  most 
cases  say  positively  that  shortening  does  or  does  not  exist,  and  if 
present,  estimate  its  amount  and  locate  it  exactly. 

Occasionally  a  person  is  found  whose  legs  differ  in  length  by 
as  much  as  an  inch.  If  such  a  one  sprains  his  hip  on  the  short 
side,  the  diagnosis  will  be  obscure  for  a  few  days  until  the  prompt 
recovery  rules  out  any  serious  injury.  The  author  met  one  such 
case  in  a  boy  aged  fourteen. 

Finally,  functions  of  the  joint  are  to  be  tested.  The  various 
motions  of  which  the  joint  is  capable,  adduction,  abduction,  flex- 
ion, extension,  and  external  and  internal  rotation,  are  to  be  per- 
formed both  passively  and  actively,  and  limitation  of  motion,  pain, 
and  muscular  spasm  are  to  be  noted.     Muscular  spasm  is  most 


SPRAIN  OF  THE   KNEE  489 

marked  in  tuberculosis,  especially  on  overextension  or  external 
rotation.  In  fracture  there  is  loss  of  active  motion  to  a  great 
degree,  and  the  limb  is  usually  fixed  in  external  rotation,  a  de- 
formity which  cannot  be  overcome  either  actively  or  passively. 
Tuberculosis  also  gives  a  daily  fever,  at  least  of  one  or  two  de- 
grees. Impacted  fracture  should  always  be  recognized  when  pres- 
ent, by  the  abnormal  rotation  of  the  limb,  its  shortening,  the 
marked  loss  of  function,  and  the  palpable  thickening  about  the 
trochanter.  A  single  examination  may  not  serve  in  all  cases 
to  differentiate  sprain  and  tuberculosis.  The  former  will  be 
cured  by  a  few  days'  treatment  of  rest,  secured  by  a  light  spica 
bandage  of  plaster  of  Paris;  while  the  symptoms  of  the  latter 
will  only  be  somewhat  improved  by  the  bandage,  even  when  com- 
bined with  rest  in  bed,  and  will  promptly  return  and  grow  worse 
as  soon  as  the  patient  goes  about  again. 

An  unimpacted  fracture  of  the  neck  of  the  femur,  having  the 
unmistakable  symptoms  of  shortening,  crepitus,  and  abnormal 
motion  at  the  hip,  can  scarcely  be  confounded  with  the  other 
lesions  mentioned.  In  both  impacted  and  unimpacted  fractures 
of  the  neck  of  the  femur  there  should  be  found  displacement  of 
the  trochanter  upward. 

Treatment. — The  treatment  of  sprain  or  contusion  of  the 
hip  consists  of  rest  in  bed,  with  external  heat  or  counter-irritants 
to  control  pain.  The  patient  should  be  early  encouraged  to  make 
the  motions  of  flexion  and  rotation  at  the  hip- joint  while  still 
in  a  recumbent  position.  As  soon  as  tenderness  subsides  the  nor- 
mal use  of  the  limb  should  be  resumed.  Such  an  injury  is  most 
apt  to  occur  in  the  aged,  and  the  early  use  of  their  joints  is  to 
be  encouraged,  in  order  to  avoid  stiffness.  But  first  there  should 
be  a  careful  examination  to  exclude  fracture,  and  second,  the 
patient  should  be  assisted  in  the  early  attempts  to  walk,  lest  a 
second  fall  add  to  the  existing  injury. 

Sprain  of  the  knee  produces  some  or  all  of  the  following  symp- 
toms: Pain;  tenderness,  especially  if  extreme,  flexion  or  exten- 
sion is  attempted;  partial  loss  of  function;  swelling  of  the  soft 
tissues,  and  effusion  of  fluid  into  the  joint  cavity.  If  one  of  the 
lateral  ligaments  is  torn  there  will  also  be  an  abnormal  lateral 
motion  in  the  joint  when  manipulated.  The  last  named  sign  com- 
ing on  suddenly  after  an  injury  is  pathognomonic;  but  continued 


-I'M) 


I  N.l  TRIES   OF  THE   LEG    AND   FOOT 


distention  of  the  joinl  cavity  w 
joint,  so  that  abnormal  lateral 
Demonstration  of  Fi.ru> 
joint  is  best  demonstrated  by 
the  quadriceps"  tendon  with  the 
of  the  other  hand  pushes  the  pi 
to  the  femur  (Fig.  264).  T 
thiii'h  and  the  muscles  relaxed 


ill  also  stretch  the  ligaments  of  the 

motion  is  obtainable. 
in  the  Joint. — Fluid  in  the  knee- 
ion  i  pressing  the  cul-de-sac  beneath 

palm  of  tlic  hand,  while  one  finger 
atella  lightly  but  quickly  backward 
he  leg  should  be  extended  on  the 
during  this  test.     If  the  joint  con- 


Fig.  264. — Demonstration  of  Floating  Patella. 

tains  no  fluid,  the  patella  is  in  contact  with  the  femur,  and  noth- 
ing happens  when  it  is  thrust  backward.  If  the  joint  contains 
even  a  little  fluid,  the  position  of  the  limb  and  the  compression 
of  the  upper  hand  (left  in  the  figure)  forces  the  fluid  into  the 
lower  and  anterior  part  of  the  joint  and  the  patella  is  separated 
from  the  femur.  The  sudden  thrust  of  the  finger  pushes  the 
patella  backward  through  the  fluid,  and  it  strikes  the  femur  with 
an  appreciable  click. 

The  fluid  in  the  knee-joint  after  a  sprain  is  usually  serous, 
though  it  may  be  bloody  if  the  injury  is  more  severe.  Fluid  is 
not  pathognomonic  of  sprain,  since  it  may  be  caused  by  internal 


SPRAIN  OF  THE  KNEE  491 

sources  of  irritation,  as  is  mentioned  below,  and  in  some  cases 
no  fluid  can  be  demonstrated  in  the  joint,  even  though  a  sprain  is 
known  to  have  occurred. 

Differential  Diagnosis. — In  differential  diagnosis  with 
sprain  of  the  knee-joint  one  must  consider  prepatellar  bursitis, 
rupture  of  a  lateral  ligament,  reduced  dislocation  of  the  knee, 
dislocation  of  a  meniscus,  loose  or  floating  cartilage,  and  the  vari- 
ous acute  and  chronic  inflammatory  disorders  of  joints  to  which 
the  knee  is  especially  subject,  and  sarcoma.  For  a  full  list  of 
the  symptoms  of  these  various  diseases  the  reader  should  look 
under  the  appropriate  heads,  as  only  the  most  striking  differences 
are  here  given. 

In  prepatellar  bursitis  the  fluid  is  confined  in  a  compara- 
tively small  sac,  which  lies  in  front  of  the  patella  and  not  behind 
it,  as  in  sprain,  and  the  functions  of  the  joint  are  not  affected 
by  it. 

Rupture  of  a  lateral  ligament  gives  abnormal  lateral  mobil- 
ity; reduced  dislocation  may  be  recognized  by  this  same  sign,  or 
possibly  only  by  the  history. 

A  patient  with  displacement  of  a  meniscus  usually  gives  a 
history  of  repeated  attacks  of  painful  locking  of  the  joint,  fol- 
lowed by  fluid  in  the  joint  and  limitation  of  motion  for  a  few 
days.  Sometimes  palpation  will  reveal  an  alteration  in  the  joint 
about  the  base  of  the  loosened  meniscus. 

A  loose  or  floating  cartilage  will  often  have  been  detected  by 
the  patient,  who  may  be  able  to  demonstrate  its  presence  by  bring- 
ing it  to  one  side  of  the  joint.  It  keeps  up  the  effusion  in  the 
joint  to  an  extent  not  warranted  by  the  history  of  injury,  and 
indeed  may  exist  without  any  pain  or  loss  of  function. 

Acute  suppuration  in  the  knee-joint,  following  a  punctured 
wound  for  example,  on  account  of  the  great  surface  of  the  joint 
cavity  produces  much  pain,  swelling,  fever,  etc.  It  is  a  serious 
condition  which  cannot  be  confounded  with  slight  injuries.  A 
puncture  of  the  knee-joint  without  suppuration  does  not  prevent 
a  patient  from  walking  about.  It  should  be  recognized  by  the 
tenacious  character  of  the  escaping  fluid,  not  by  the  probe.  Such 
a  wound  should  be  cleansed  and  dressed  at  once,  a  posterior  splint 
applied,  and  the  patient  put  to  bed,  lest  he  suffer  the  much  greater 
ills  of  a  suppurating  joint. 


492  INJURIES   OF   THE   LEG  AND   FOOT 

Acute  rheumatism  (.'Mines  on  without  injury,  gives  a  fever,  and 
usually  involves  more  than  one  joint. 

Gonorrheal,  gouty,  tuberculous,  and  syphilitic  arthritis  are 
also  slowly  progressing  affections  with  local  and  general  symptoms 
of  inflammation.  If  the  inflammation  is  not  marked  and  the  dis- 
ability of  the  knee  is  first  noticed  after  some  traumatism,  a  mis- 
take in  diagnosis  is  possible,  but  a  careful  history  and  examina- 
tion will  clearly  separate  these  lesions  from  a  sprain. 

Arthritis  deformans  is  a  progressive  affection  which  alters  the 
ends  of  the  bones,  gives  little  or  no  fluid  in  the  joints,  and  limits 
motions  very  greatly.      It  usually  occurs  independent  of   injury. 

Sarcoma  of  the  lower  end  of  the  femur  is  more  likely  to  be 
mistaken  for  tuberculosis  than  for  a  traumatism  of  the  joint. 
It  always  enlarges  the  bone,  a  point  which  can  be  demonstrated 
by  the  X-ray  if  not  by  the  fingers. 

Treatment.- — The  essentials  of  treatment  of  a  sprain  of  the 
knee  are  rest  to  the  joint  and  compression.  These  ends  can  be 
secured  by  a  posterior  splint  and  bandage.  An  excellent  splint 
is  made  by  wetting  a  plaster  of  Paris  bandage  and  drawing  it 
back  and  forth  on  a  board  fifteen  or  twenty  times,  a  distance  of 
two  feet  or  more,  according  to  the  length  of  the  patient's  limb. 
It  should  reach  from  the  ankle  to  the  great  trochanter.  The 
layers  of  the  bandage  should  be  well  rubbed  together  as  they  are 
applied  to  each  other,  so  that  the  splint  when  completed  shall 
be  one  solid  piece.  Three  bandages,  each  three  inches  wide,  are 
needed.  The  splint  should  be  bandaged  in  position  immediately, 
so  that  it  may  take  the  shape  of  the  bare  limb  before  it  sets. 
If  the  limb  is  hairy,  it  should  be  smeared  with  vaseline  or  shaved. 
When  the  splint  is  hard  it  may  be  removed  and  covered  with 
canton  flannel,  reapplied,  and  held  in  position  by  a  soft  bandage. 
A  pure  flannel  bandage  may  be  used  for  this  purpose.  If  an 
inelastic  bandage  is  used,  the  knee  should  be  covered  anteriorly 
with  a  broad  pad  of  cotton,  so  that  elastic  pressure  may  be 
obtained.  The  splint  should  be  broad  enough  to  enclose  fully 
one-third  of  the  circumference  of  the  limb,  and  the  leg  should 
not  be  absolutely  extended  on  the  thigh  when  the  splint  is  applied, 
but  should  make  with  it  an  angle  of  about  one  hundred  and  sixty- 
five  degrees.  This  gives  the  knee  the  greatest  comfort  wdien  the 
patient  is  walking,  sitting,  or  lying.      Such  is  the  initial  treat- 


SPRAIN    OF  THE  ANKLE 


193 


ment  for  a  sprain  of  moderate  degree.  If  the  sprain  is  more 
severe,  or  if  one  of  the  lateral  ligaments  is  ruptured,  the  patient 
should  not  be  allowed  to  put  any  weight  on  the  limb,  and  should 
lie  in  bed  or  go  about 
on  crutches. 

A  pleasanter  meth- 
od of  treatment,  appli- 
cable to  slight  sprains 
or  more  severe  ones 
after  the  first  or  second 
week,  is  the  strapping 
of  the  joint,  laterally 
and  anteriorly,  with 
strips  of  adhesive  plas- 
ter laid  on  diagonally 
(Fig.  265). 

Still  another  meth- 
od is  daily  massage  and 
the  application  of  an 
elastic  bandage  of  flan- 
nel or  rubber,  without 
any  splint. 

Sprain  of  the  Ankle. 
— The  ankle  is  more 
often  sprained  than  any 

other  joint  of  the  lower  extremity.  For  convenience,  it  is  well 
to  consider  these  sprains  in  three  classes,  according  to  the  degree 
of  the  injury,  whether  slight,  medium,  or  severe.  In  almost  all 
cases  the  foot  is  turned  inward,  so  that  any  tearing  of  the  liga- 
ments which  occurs  is  usually  on  the  outer  aspect. 

Spbain  of  Slight  Degree. — In  a  slight  sprain  of  the  ankle 
there  is  a  little  pain  and  tenderness  and  a  little  swelling,  espe- 
cially below  the  external  malleolus.  The  patient  walks  without 
difficulty,  and  there  is  no  abnormal  motion  of  the  foot. 

Treatment. — For  the  first  and  second  day  following  the  in- 
jury the  limb  should  be  kept  in  a  horizontal  position  and  treated 
by  hot  fomentations,  light  massage,  and  passive  motions  two  or 
three  times  a  day.  On  the  third  day  and  thereafter  it  should 
have  a  hot  douche  for  thirty  minutes,  followed  by  a  cold  douche 


Fig.    265. 


-Strapping    with    Adhesive    Plaster 
for  Sprain  of  the  Knee. 


494  INJURIES   OF  THE   LEG   AND   FOOT 

for  a  minute,  and  this  followed  by  massage.  This  treatment 
should  be  repeated  twice  a  day  and  active  motion  begun,  the 
patient  being  allowed  to  walk. 

Another  plan  is  to  apply  adhesive  strapping  at  once,  as  de- 
scribed below. 

Si'K.ux  of  Medium  Severity. — If  the  sprain  is  of  medium 
degree,  the  pain  and  tenderness  are  more  marked,  the  swelling 
is  greater  and  involves  the  whole  circumference  of  the  ankle,  and 
there  is  more  difficulty  in  walking.  Some  of  the  ligaments  are 
ruptured,  and  in  addition  there  is  probably  contusion  of  the  articu- 
lar surfaces  of  the  bones. 

The  treatment  described  above  for  slight  sprain  may  be  car- 
ried out  for  forty-eight  hours;  or  a  flannel  bandage  may  be  firmly 
applied  from  the  toes  to  the  knee  and  the  limb  soaked  in  water 
at  110  to  115  degrees  for  three  or  four  hours  to  prevent  swelling. 

After  this  preliminary  treatment  with  hot  water,  or  hot 
fomentations  and  massage,  adhesive  straps  should  be  applied  to 
the  foot,  ankle,  and  leg.  They  serve  a  threefold  purpose,  keep- 
ing the  foot  in  a  correct  position,  preventing  extreme  motion  in 
any  direction,  and  exerting  automatic  massage  by  varying  the 
pressure  in  different  parts  every  time  the  foot  is  moved. 

The  leg  should  be  shaved,  washed  with  soap  and  hot  water, 
alcohol,  and  ether.  Strips  of  adhesive  plaster  should  be  applied 
in  such  a  manner  that  they  will  fit  accurately  and  each  will  overlap 
the  next  by  a  third  of  an  inch.  The  exact  pattern  makes  little  dif- 
ference, since  the  individual  strips  are  soon  welded  into  a  single 
casing.  A  good  plan  is  to  apply  a  broad  strip  like  a  stirrup,  ex- 
tending from  below  the  knee  on  the  inner  side  of  the  leg,  cover- 
ing the  inner  malleolus,  the  plantar  surface  of  the  heel,  the  outer 
malleolus,  and  finishing  on  the  outer  surface  of  the  leg  near  the 
head  of  the  fibula.  In  applying  this,  the  foot  should  be  held  at 
a  right  angle  to  the  leg,  and  in  a  correct  position  laterally,  or 
possibly  slightly  abducted,  in  order  to  relax  the  strain  on  the 
injured  ligaments.  Additional  strips  not  more  than  an  inch 
wide  should  circle  the  heel  horizontally,  and  reach  to  the  base  of 
the  toes  (Fig.  266).  These  should  be  carried  well  above  the 
ankle.  If  there  is  fear  that  the  swelling  will  inerease,  these  hori- 
zontal strips  may  be  stopped  before  they  meet  in  front,  although 
the  support  in  that  case  will  be  less  firm.     A  light  gauze  bandage 


SPRAIN   OF  THE   ANKLE 


495 


completes  the  dressing.  On  the  third  day  the  patient  can  walk 
about  with  a  cane,  but  the  massage  and  passive  motion  should  be 
continued. 

If  the  adhesive  plaster  becomes  loose,  it  should  be  removed  and 
renewed.     After  two  weeks  it  may  be  removed,  but  douches  and 


Fig.   266. — A  Good  Method  of  Strapping   a   Sprained  Ankle  with   Adhesive 

Plaster. 

massage  should  then  be  resumed  and  continued  as  long  as  the 
joint  is  weak. 

Some  surgeons  prefer  cold  to  heat  in  the  early  treatment  of 
these  sprains,  and  keep  an  ice-bag  in  contact  with  the  ankle  for 
a  part  of  each  day  after  the  adhesive  plaster  has  been  applied. 
This  plan  works  well  in  some  cases,  but  must  be  used  with  cau- 
tion if  the  patient  is  old  or  feeble. 

Sprain"  of  Extreme  Severity. — In  sprains  of  extreme  de- 
grees of  severity  there  is  marked  pain  and  swelling,  and  a  great 
deal  of  abnormal  motion,  amounting  to  a  partial  dislocation.  One 
often  suspects  a  fracture  of  one  malleolus,  although  it  may  be 
impossible  to  prove  this  without  a  radiographic  examination. 

The  plan  of  treatment  is  as  follows :  One  should  elevate  the 
limb  and  apply  hot  fomentations  to  relieve  the  pain,  and  keep 
them  hot  with  hot  water  bags,  which  can  be  changed  from  time 
to  time  without  disturbing  the  wet  cloths.  The  limb  should  be 
fixed  by  sandbags,  not  too  tightly  filled.  Two  or  three  times  a 
day  the  dressing  should  be  removed,  and  gentle  massage  given 


496  1  WITHIES   OF    THE   lkcj   and  FOOT 

without  disturbing  the  joint.  A  bed  rcsl  should  keep  the  clothes 
from  touching  the  foot.  On  the  third,  fourth,  or  fifth  day,  when 
the  swelling  has  somewhat  subsided,  the  leg  should  be  shaved, 
covered  with  sheet  wadding,  and  encased  in  a  plaster  of  Paris 
bandage  from  the  toes  to  the  knee,  the  foot  being  held  at  a  right 
angle.     The.  patient  may  go  about  on  crutches. 

After  two  weeks  the  cast  should  be  removed,  a  hot  douche 
and  massage  should  be  given  twice  a  day,  and  passive  and  active 
motion  begun.  The  patient  should  bear  his  full  weight  on  the 
injured  foot  in  three  or  four  weeks,  according  to  the  degree  of 
injury. 

Molded  gypsum  splints  may  also  lie  used.  (See  Figs.  270  and 
271,  p.  506.)  They  are  easily  removed  for  massage  and  can  be 
reapplied  by  the  patient. 

Recurrent  Sprain  of  Ankle. — The  ankle  is  especially  liable  to 
a  resprain,  and  hence  it  is  desirable  in  many  instances  to  advise 
the  patient  to  protect  the  joint  long  after  the  external  evidences 
of  injury  have  disappeared.  Many  persons  prefer  a  woven  rub- 
ber anklet,  or  one  made  of  leather,  which  laces  up,  to  the  daily 
application  of  a  bandage.  Such  apparatus  is  more  serviceable 
at  the  ankle  than  at  the  knee,  as  the  more  limited  range  of  motion 
at  the  ankle  and  the  different  shape  of  the  parts  make  it  easy  to 
keep  it  in  place. 

Rupture  of  a  Lateral  Ligament  of  the  Knee. — This  in- 
jury is  usually  produced  by  direct  violence.  A  heavy  body,  for 
instance,  a  falling  sack  of  grain,  strikes  against  the  leg  or  knee, 
when  the  foot  and  body  are  fixed.  The  result  is  an  undue  stretch- 
ing of  the  ligaments  on  the  opposite  side  of  the  knee,  with  rupture. 
If  this  rupture  is  not  too  extensive,  the  patient  can  walk  about, 
but  he  is  careful  to  use  the  limb  in  such  a  manner  as  to  prevent 
strain  being  brought  on  the  ruptured  ligament.  Pain  after  this 
injury  is  slight  if  the  limb  is  kept  at  rest.  There  is  often  very 
little  ecchymosis,  and  the  swelling  may  not  be  excessive.  The 
pathognomonic  symptom  is  an  abnormal  lateral  motion,  best  shown 
as  follows :  Let  the  patient  lie  on  his  back,  or  lean  back  in  a 
chair,  with  both  legs  at  rest  in  a  horizontal  position.  Test  the 
lateral  mobility  of  the  sound  knee  by  grasping  the  leg  firmly 
above  the  ankle,  and  using  the  other  hand  as  a  fulcrum  placed 
against  the  patient's  knee.     Test  first  the  internal  and  then  the  ex- 


FRACTURE  OF  THE  FEMUR  407 

ternal  ligament.  Repeat  the  tests  on  the  injured  side.  If  one  of 
the  ligaments  is  ruptured  moderate  force  will  swing  the  leg  away 
from  its  normal  line  to  an  appreciable  angle,  perhaps  twenty  or 
thirty  degrees.  When  the  leg  is  relaxed  it  swings  back  into  line 
with  a  peculiar  snap,  which  is  easily  remembered  if  it  has  once 
been  felt.  It  is  something  like  the  snap  with  which  the  lid  of  a 
match-box  closes,  if  there  is  a  spring  in  its  hinge.  Treatment 
is  similar  to  that  for  severe  sprain,  plus  a  longer  protection  of 
the  ligament  by  a  posterior  splint.  The  patient  should  remain  in 
bed  a  few  days,  sit  about  or  walk  with  crutches  for  ten  days  more, 
and  wear  a  splint  for  another  two  weeks  at  least.  Massage  and 
passive  motions  are  indicated  after  the  first  week  or  so. 

Dislocations. — Dislocations  of  the  larger  joints  of  the  lower 
extremity  are  rare  and  serious  lesions,  which  are  not  seen  in  ambu- 
lant practise. 

Dislocation  of  one  of  the  toes  sometimes  occurs.  In  diagno- 
sis and  treatment  it  closely  resembles  dislocation  of  a  finger,  which 
see  (p.  357). 

Fracture  of  the  Femur. — Most  of  the  fractures  of  the 
femur  are  too  serious  to  find  a  place  in  a  text-book  on  minor 
surgery  except  in  so  far  as  they  have  to  be  considered  in  the 
differential  diagnosis  of  sprains  and.  contusions.  It  is,  however, 
possible  for  a  patient  to  fracture  the  femur  and  yet  walk  about. 
This  is  sometimes  the  case  after  impacted  fracture,  and  walking 
is  possible  after  fracture  of  the  great  trochanter. 

Fracture  of  the  Great  Trochanter. — This  rare  injury 
is  caused  by  a  fall  or  blow  directed  against  the  great  trochanter, 
a  part  of  which  may  then  be  separated  from  the  femur,  remain- 
ing attached  to  the  gluteal  tendon. 

The  diagnosis  is  not  difficult.  There  is  a  local  pain,  swelling, 
and  ecchymosis.  The  patient  walks  guardedly,  and.  gets  up  and 
sits  down  with  pain  and  difficulty.  Palpation  reveals  the  loosened 
fragment,  which  may  also  be  shown  in  a  good  radiograph  (Fig. 
267). 

All  the  treatment  that  is  necessary  is  to  press  the  trochanter 
firmly  against  the  shaft  of  the  femur  by  a  strip  of  adhesive  plas- 
ter and  to  keep  the  patient  in  bed  two  or  three  weeks.  The 
bone  united  firmly  in  the  case  of  the  patient  referred  to  in 
Figure  267. 


49S 


INJURIES    OF   THE    LEG    AND    FOOT 


Fracture  of  Patella. — The  patella  may  be  broken  by  direct 
violence,  as  by  a  fall  on  the  knee ;  or  by  indirect  violence,  when  a 
sudden  strain  is  brought  upon  the  tendon  of  the  quadriceps  ex- 
tensor. In  the  first  case  the  fracture  may  be  single  or  multiple, 
and  the  separation  of  the  fragments  slight  or  extreme,  and  there 


Fig.  267. — Radiograph  of  a  Male  Patient  Who  Fractured  His  Right  Great 
Trochanter  by  a  Fall.     The  uninjured  trochanter  is  shown  for  comparison. 

may  or  may  not  be  rupture  of  the  strong  aponeuroses  at  the  sides 
of  the  patella.  These  aponeuroses  form  so  important  a  part  of 
the  extension  apparatus  that  if  they  are  not  ruptured  the  patient 
may  be  able  to  extend  his  leg. 

If  the  fracture  is  due  to  indirect  violence,  it  is  almost  always 
single  and.  transverse,  the  lateral  aponeuroses  are  apt  to  be  torn, 
and  the  gap  between  the  fragments  is  proportionately  wide.  Diag- 
nosis is  usually  easily  made  by  the  history  of  the  accident,  by 
direct  palpation  of  the  fragments,  by  the  presence  of  a  gap  which 
is  lessened  by  pressure  together  of  the  fragments  and  increased 
when  the  leg  is  flexed,  and  by  the  inability  of  the  patient  to  extend 
the  flexed  leg,  although  this  can  be  readily  performed  by  passive 
motion.      Accompanying   signs   are    swelling,    ecchymosis    (often 


FRACTURE  OF  PATELLA 


490 


absent),  and  fluid  in  the  joint  (cither  serum  or  blood).  If  the 
swelling  is  not  great,  crepitus  may  be  obtained  by  crowding  the 
fragments  together,  and  moving  one  on  the  other. 

Treatment. — The  limb  should  be  extended  on  a  molded  pos- 
terior splint  for  four  weeks,  more  or  less,  during  which  time  the 
fragments  should  be  held  in  apposition  in  one  of  four  ways:  (a) 
by  strips  of  adhesive  plaster,  or  (6)  by  a  suitably  dimpled  plaster 
of  Paris  circular  bandage,  or  (c)  by  suture  of  the  aponeuroses  at 
the  sides  of  and  in  front  of  the  patella,  or  (d)  by  suture  of  the 
fragments  themselves.  If  the  fragments  cannot  be  approximated 
digitally,  neither  (a)  nor  (b)  is  a  suitable  mode  of  treatment. 

The  posterior  splint  necessary,  if  plan  (a),  (c),  or  (d)  is 
followed,  is  best  made  of  plaster  of  Paris,  according  to  direc- 
tions on  page  707.  The 
leg  should  be  fully  ex- 
tended when  the  splint 
is  applied.  "When  the 
splint  has  set,  it  should 
be  removed,  fully  dried, 
and  covered  with  can- 
ton flannel.  It  may  be 
bandaged  to  the  limb, 
or  held  in  place  with 
several  pieces  of  broad 
tape  or  light  webbing, 


brought 


together 


front  with  buckles. 

If  plan  (a)  is  fol- 
lowed, the  limb  is 
shaved  about  the  knee, 
the  fragments  are  digi- 
tally approximated,  and 
fixed  by  two  strips  of 
adhesive  plaster,  one 
passing  below  the  pa- 
tella and  anchored  on 
the  sides  of  the  thigh, 

the  other  passing  above  the  patella  and  anchored  on  the  sides  of 
the  leg  (Fig.  268).     If  these  tilt  the  fragments  a  third  strip  may 
34 


Fig.  268. — A  Demonstration  of  the  Method  of 
Applying  Strips  of  Adhesive  Plaster  to 
Approximate  the  Fragments  After  Frac- 
ture of  the  Patella. 


500  INJURIES   OF   THE   LEG   AND   FOOT 

be  applied  directly  across  the  patella.  The  posterior  splint  should 
then  be  applied. 

If  plan  (6)  is  followed,  the  fragments  arc  approximated  digi- 
tally by  the  surgeon,  -while  the  assistant  applies  a  circular  plaster 
of  Paris  bandage  from  above  the  ankle  to  the  upper  part  of  the 
thigh.  The  limb  is  kept  in  full  extension  by  lifting  it  and  placing 
the  foot  on  a  box  some  twelve  inches  above  the  level  of  the  bed 
or  tattle  on  which  the  patient  is  lying.  Sheet  wadding  or  some 
similar  material  is  evenly  spread  over  the  whole  limb.  As  the  as- 
sistant carries  the  bandage  across  the  knee,  the  surgeon  carefully 
removes  his  fingers,  one  at  a  time,  and  quickly  replaces  them,  thus 
keeping  Tip  pressure  at  the  points  at  which  he  has  found  that  he 
can  best  overcome  displacement  of  the  fragments.  This  procedure 
is  repeated  as  often  as  the  circular  turns  of  the  plaster  bandage 
pass  the  knee.  When  the  splint  is  completed  there  will  be  in  it  four 
or  more  depressions  made  by  the  finger-tips,  and  so  disposed  that 
they  prevent  the  fragments  of  patella  from  becoming  separated. 

The  accumulation  of  much  fluid  in  the  knee-joint  will  inter- 
fere with  the  successful  employment  of  plans  (a)  and  (&).  The 
pressure  of  a  rubber  or  other  elastic  bandage  may  cause  its  resorp- 
tion in  a  few  days.  If  not,  it  may  be  evacuated  with  a  medium 
sized  trocar  and  cannula,  or  better,  through  a  quarter-inch  incision. 
The  risk  of  infection  is  extremely  slight  if  the  skin  is  washed  with 
soap  and  water,  turpentine,  and  alcohol,  and  the  instrument  is 
boiled  and  its  point  not  handled.  Local  anesthesia  suffices.  The 
opening  should  be  made  at  the  side  of  the  knee,  and  far  enough 
back  to  be  out  of  the  way  of  the  adhesive  strips. 

Treatment  by  Operation:  Plans  (c)  and  (d). — If  digital 
approximation  of  the  fragments  is  impossible  on  account  of  the 
presence  of  fascia  between  the  fragments  or  for  any  other  reason, 
ligamentous  or  bony  suture  should  be  advised — plans  (c)  and  (d). 
Both  of  these  entail  the  risk  of  sepsis,  which  in  the  knee  may  be 
serious ;  but  in  favorable  cases  the  period  of  recovery  is  lessened 
and  the  union  of  the  fragments  is  stronger  than  in  many  of  the 
cases  treated  without  operation.  Therefore,  operation  is  advisable 
even  in  many  cases  in  which  digital  approximation  can  be  achieved. 
A  transverse  incision  of  the  skin,  removal  of  blood  clots  from  the 
joint  cavity,  and  suture  of  the  lateral  aponeurotic  tears  and  of  the 
gap  in  the  strong  fascia  anterior  to  the  patella  itself,  with  twenty 


FRACTURE  OF  THE  TIBIA  501 

day  chromic  catgut,  is  the  simplest  operation.  But  good  results 
have  been  obtained  by  suture  of  the  bony  fragments,  or  by  passing 
a  string  around  the  patella,  or  by  other  methods  of  approximation. 
The  materials  used  have  been  wire  and  silk,  as  well  as  absorbable 
materials.  The  skin  wound  is  to  be  sutured  without  drainage, 
and  a  posterior  splint  applied. 

In  the  after  treatment,  massage  is  a  valuable  aid.  It  may  be 
begun  as  early  as  the  fourth  day,  care  being  exercised  not  to  pull 
upon  the  fragments.  Passive  motions  may  be  employed  in  two 
weeks,  but  they  should  be  slight  in  extent  until  there  is  plainly 
union  between  the  fragments.  By  these  methods  stiffness  of  the 
knee  may  be  avoided.  They  cannot  be  employed  if  plan  (b)  is 
adopted,  and  hence  the  circular  splint  should  be  cut  away  in  two 
weeks,  and  a  new  one  applied,  or  a  change  in  treatment  may  then 
be  made  to  plan  (a) — the  use  of  adhesive  strips. 

A  patient  should  walk  with  a  shortened  posterior  splint  in  four 
weeks,  but  he  should  not  attempt  to  bring  strain  upon  the  fractured 
patella,  and  such  motions  as  kneeling  or  using  that  limb  for  stair 
climbing  should  be  forbidden  for  three  months. 

Fracture  of  the  Tibia.— Delayed  Union. — Fracture  of  the 
tibia  and  fibula  coexisting,  and  fracture  of  the  tibia  alone  above 
the  malleolus,  are  excluded  from  ambulant  practise.  Patients  with 
such  lesions  may  come  for  treatment  some  weeks  after  the  in- 
jury, the  bones  not  yet  having  united  properly.  It  is  therefore  well 
to  consider  the  treatment  of  non-union  of  the  tibia.  Palpation 
will  reveal  the  plane  of  the  fracture.  The  leg  should  be  grasped 
firmly  above  the  fracture  with  one  hand,  and  below  the  fracture 
with  the  other.  By  a  firm,  quick  motion,  the  broken  bone  should 
be  tested  for  abnormal  mobility.  This  test  should  be  applied  both 
laterally  and  anteroposteriorly.  The  position  of  the  fragments, 
when  at  rest  and  when  the  patient  bears  weight  on  the  injured  limb, 
should  also  be  noted.  All  of  these  facts  should  be  recorded  for 
future  comparison.  Radiographs  should  also  be  made  in  two 
planes. 

Treatment. — The  treatment  will  depend  upon  the  conditions 
present.  If  the  deformity  is  not  extreme,  or  can  be  manually 
corrected,  and  if  the  fractured  ends  of  the  bone  are  in  contact  or 
can  be  brought  into  contact  without  producing  too  great  deformity, 
union  may  be  obtained  by  the  following  plan  of  treatment :  Make 


502  INJURIES   OF  THE   LEG   AND   FOOT 

two  lateral  molded  plaster  of  Paris  splints  to  reach  from  the 
ankle  nearly  to  the  knee.  Each  should  be  broad  enough  to  cover 
ahoul  one-third  of  the  circmnt'erenee  of  the  limb.  This  gives  them 
a  tinner  grasp,  and  the  curve  adds  greatly  to  their  strength.  When 
they  have  set  they  should  be  removed,  dried,  covered  with  canton 
flannel,  and  affixed  to  the  leg  with  cloth  straps  and  buckles.  Every 
day,  or  every  second  day,  the  fractured  ends  of  the  bone  should 
be  ground  together  by  the  surgeon  for  two  or  three  minutes  or  more, 
according  to  the  temperament  of  the  patient.  This  is  not  so  painful 
a  procedure  as  it  sounds,  and  no  anesthetic  is  required.  The 
splints  should  be  firmly  strapped  in  place,  and  the  patient  en- 
couraged to  walk  about  with  crutches,  yet  bearing  much  of  his 
weight  on  the  injured  leg.  This  treatment  should  be  repeated 
until  there  is  tenderness  and  swelling  at  the  site  of  fracture.  The 
grinding  of  the  bones  together  may  then  be  performed  less  often, 
allowing  time  between  treatments  for  the  tenderness  to  subside 
somewhat,  but  not  enough  for  all  signs  of  irritation  to  disappear. 
In  two  or  three  weeks  increased  callus  interferes  with  the  grind- 
ing of  the  bones'  on  each  other,  and  this  part  of  the  treatment  may 
then  be  omitted;  but  the  patient  should  increase  his  exercise,  and 
bear  more  weight  on  the  limb.  In  many  cases  a  complete  bony 
union  will  result  in  one  or  two  months. 

If  there  is  bad  angular  deformity  which  cannot  be  corrected 
manually,  or  if  the  ends  of  the  tibia  are  plainly  separated,  and 
cannot  be  brought  into  contact  except  by  producing  an  angular 
deformity,  as  is  often  the  case  after  compound  fracture  with  loss 
of  bone  (non-union  after  operation),  the  treatment  above  outlined 
is  not  indicated  and  operation  must  be  considered. 

It  is  also  well  to  remember  that  a  united  fibula  may  keep 
apart  the  ends  of  a  fractured  tibia,  especially  if  there  is  loss  of 
the  tibial  substance.  The  author  has  seen  two  cases  of  failure 
after  operation  for  non-union  of  the  tibia,  which  wTere  clearly  due 
to  this  cause,  as  in  both  cases  the  condition  was  the  same.  There 
had  been  no  resection  of  the  fibula,  and  the  cut  ends  of  the  tibia 
could  not  be  approximated  except  by  producing  a  bad  angular 
deformity. 

Fracture  of  the  Fibula. — Fracture  of  the  shaft  of  the 
fibula  is  usually  the  result  of  direct  violence,  but  the  bone  may  be 
I  roken  near  its  upper  extremity  by  a  sudden  pull  of  the  biceps 


FRACTURE  OF  THE    FIBULA  503 

muscle.  As  the  greater  portion  of  the  fibula  is  covered  by  thick 
muscles,  fracture  of  its  shaft  may  exist  without  the  usual  signs  of 
swelling,  ecchymosis,  and  crepitus.  Palpation  is  unsatisfactory, 
and  the  patient  may  be  able  to  walk.  Hence  it  is  no  uncommon 
thing  for  a  fracture  of  this  character  to  be  overlooked.  Positive 
signs  are  shortening  of  the  fibula,  measured  from  end  to  end,  jmiii 
on  direct  pressure,  pain  on  pressure  upon  the  bone  at  a  distance 
from  the  point  of  fracture,  and  absolute  inability  of  the  patient  to 
lift  the  heel  from  the  floor  while  bearing  weight  on  the  injured 
limb.  The  reason  of  this  is  obvious.  The  heel  is  raised  in  part  by 
the  action  of  the  flexor  longus  pollicis,  and  longus  and  brevis  pero- 
nei  muscles.  These  muscles  arise  from  almost  the  whole  length  of 
the  fibula,  and  their  contraction  disturbs  the  fragments  of  the, 
broken  bone.  If  the  break  is  in  the  lower  part  of  the  shaft  of  the 
fibula,  displacement  of  fragments,  crepitus,  and  false  motion  can 
usually  be  made  out  in  addition  to  the  signs  given  above. 

Treatment. — If  the  patient  chooses  to  remain  in  bed,  no 
apparatus  is  necessary  other  than  small  pillows  or  sandbags  to 
steady  the  leg,  and  a  cradle  to  keep  the  clothes  from  resting  on 
the  limb ;  but  in  most  cases  it  is  desirable  to  apply  a  light  plaster 
of  Paris  bandage  from  the  toes  to  the  knee,  with  the  foot  at  a  right 
angle  to  the  leg.  The  following  day  the  patient  may  go  about  on 
crutches.  During  the  first  week,  when  sitting  or  lying,  the  foot 
should  be  kept  at  least  as  high  as  the  hips  in  order  to  counteract 
the  tendency  to  swell. 

The  immediate  application  of  a  circular  bandage  of  plaster  of 
Paris  is  often  advised  against  on  account  of  the  risk  of  swelling  in 
a  constricted  space.  When  the  injury  is  a  slight  one,  as  in  frac- 
ture of  the  fibula  without  severe  contusion,  this  risk  is  slight.  In 
all  cases,  however,  the  toes  should  be  left  uncovered  for  inspection. 
They  should  remain  warm,  and  the  circulation  should  remain 
active.  The  blood  should  return  quickly  to  the  surface  when  pres- 
sure made  with  the  finger  is  removed.  Such  inspection  should 
be  repeated  every  few  hours  for  a  day  or  so,  especially  if  the 
patient  complains  of  a  tight  feeling  or  pain.  In  cases  of  doubt,  it 
is  better  to  cut  the  splint  down  the  front.     It  need  not  be  removed. 

After  the  second  day  the  patient  may  go  about  with  crutches, 
and  may  begin  to  bear  a  little  weight  on  the  foot  after  the  third 
week,  increasing  the  pressure  gradually,  but  not  bearing  full  weight 


504  INJURIES   OF   THE   LEG   AND    FOOT 

"ii  the  fool  for  a1  teasl  four  weeks.     The  splint  may  be  discarded 

in  two  or  three  weeks  after  the  fracture,  according  to  the  cir- 
cumstances. 

Fractures  of  the  Tibia  and  Fibula  (Either  or  Both), 
Involving  the  Ankle-joint.— These  fractures  are  almost  in- 
variably due  to  indirect  violence.  Thev  often  follow  slips  and 
falls  on  the  street.  Many  of  them  would  be  sprains  except  for 
the  clos,.  mortising  of  the  astragalus  between  the  two  malleoli. 
Many  of  these  fractures  are  serious  injuries,  but  others  permit  the 
patienl  to  walk.  It  is  necessary  therefore  to  consider  the  whole 
class.  The  chief  end  of  treatment  after  a  fracture  is  to  restore 
function  by  obtaining  (  1  )  bony  union  of  the  fragments  in  good 
position,  and  (2)  mobility  of  the  adjacent  joints.  In  the  treat- 
ment of  fracture  involving  the  ankle-joint,  the  second  object  has 
often  been  overlooked ;  and  that  is  the  more  unfortunate,  since 
non-union  of  a  malleolus  is  very  rare. 

Diagnosis. — Diagnosis  in  these  cases  should  include  not  only 
the  determination  of  a  fracture  and  its  approximate  position,  but 
also  the  change,  if  such  exists,  in  the  relation  of  the  three  bones 
forming  the  joint,  namely  the  two  malleoli  and  the  astragalus. 
Upon  the  recognition  and  the  correction  of  such  displacement  de- 
pends the  restoration  of  the  function  of  the  limb.  In  most  cases 
it  is  well  to  examine  the  patient  under  an  anesthetic,  and  when 
possible  to  make  radiographs  of  the  ankle  in  both  anteroposterior 
and  lateral  directions. 

Displacement,  if  it  exists,  is  usually  lateral  and  backward. 
There  is  often  great  swelling  in  these  cases,  a  part  of  which  is  due 
to  the  accumulation  of  fluid,  blood,  or  serum  in  the  ankle-joint. 
This  masks  the  bony  deformity,  and  often  makes  it  impossible 
to  reduce  the  bones  properly  if  the  patient  is  first  seen  a  day  or 
two  after  the  injury. 

Treatment. — The  old  plan,  and  one  that  is  still  advocated 
by  many,  was  to  tie  the  leg  np  in  a  pillow,  or  with  side  splints, 
for  a  few  days  until  the  acute  swelling  subsides.  While  good 
results  have  many  times  been  obtained  in  this  way,  the  treatment 
is  irrational.  Tt  is  far  better  to  put  the  broken  bones  at  once 
into  as  nearly  normal  relations  as  possible.  At  a  later  day,  if  it  is 
seen  on  examination  that  the  replacement  can  be  made  even  more 
perfect,  the  surgeon  should  not  hesitate  to  reapply  the  splints, 


FRACTURES   INVOLVING  THE  ANKLE 


505 


differently  padded,  or  to  make  new  splints.  If  one  lias  at  com- 
mand a  good  X-ray  machine,  the  swelling  of  the  soft  parts  will 
not  prevent  a  correct  diagnosis ;  but  even  without  this  help  one  can 
usually  judge  of  the  character  of  the  displacement,  and  manipu- 
late the  parts  accordingly.  The  best  plan  of  treatment  is  then 
as  follows: 

Having  determined  the  site  of  fracture  and  the  degree  of  dia 
placement,  the  surgeon  should  manipulate  the  foot  until  con- 
vinced that  it  is  brought  into  a  correct  position.  Sometimes  it  is 
only  necessary  to  support  the  weight  of  the  leg  by  a  firm  grasp 
of  the  toes,  in  order  to  prevent  a  recurrence  of  the  deformity. 
A  better  plan  in  most  cases  is  to  grasp  the  heel  between  the  thumb 


Fig.  269. — Correct  Method  of  Holding  Foot  and  Leg,  During  the  Application 
of  a  Plaster  of  Paris  Splint  in  Cases  of  Fracture  of  One  or  Both 
Malleoli. 

and  two  fingers,  and  while  making  traction  with  this  hand  in  the 
long  axis  of  the  leg,  to  flex  the  ankle  to  a  right  angle  by  a  firm 
grasp  of  the  toes  (Fig.  269)  ;  or  one  may  correct  lateral  or  poste- 
rior displacement  by  grasping  the  leg  with  one  hand  and  the  heel 
with  the  other.  In  both  of  these  ways  the  foot  can  be  flexed  to 
a  right  angle  with  the  leg,  and  slightly  inverted.  According  to 
circumstances,  the  surgeon  will  hold  the  leg  or  entrust  it  to  an 
assistant.     If  his  assistant  knows  how  to  make  and  apply  a  plaster 


506  INJURIES   OF  THE   LEG   AND   FOOT 

of  Paris  splint,  and  can  bandage  it  to  the  leg,  the  surgeon  should 
hold  the  limb  in  a  correct  position,  as  this  is  the  more  important 


Fig.  270. — Strap  Splints  for  Fracture  of  the  Malleoli — in  Position. 

task.  The  making  of  strap  splints  is  described  on  page  707.  In 
this  case  two  are  required,  each  about  twenty-four  inches  long,  and 
three  or  four  inches  wide.     Three  roller  bandages  will  make  the 


Fig.  271. — Strap  Splints  for  Fracture  of  the  Malleoli — Removed. 

two.     The  posterior  is  first  applied,  and  should  reach  from  the  up- 
per part  of  the  calf  to  the  tips  of  the  toes.     Xext  a  lateral  splint, 


FRACTURE  OF  THE   ASTRAGALUS  507 

either  internal  or  external,  starting  at  the  same  level,  is  carried 
down  the  leg,  across  the  middle  of  the  sole,  and  then  across  the 
dorsum  of  the  foot,  until  it  reaches  itself,  after  having  encircled 
the  foot  (Fig.  270).  These  are  bandaged  in  place  with  a  gauze 
bandage.  The  person  who  is  holding  the  foot  in  a  correct  position 
should  not  let  go  until  the  plaster  has  set — ten  or  fifteen  minutes, 
if  it  is  fresh.  When  dry  the  splints  may  be  removed  (Fig.  271), 
lined  with  canton  flannel,  and  reapplied  ;  but  a  safer  plan  is  to 
leave  them  undisturbed  for  at  least  a  week,  as  the  lateral  splint 
never  gets  quite  such  a  firm  grip  again  after  it  has  been  removed. 

If  one  prefers  a  circular  plaster  of  Paris  splint  for  this  class 
of  injuries,  its  application  is  described  on  page  703.  The  correct 
holding  of  the  foot  and  leg  is  equally  important. 

The  object  of  flexing  the  foot  to  a  right  angle  with  the  leg  is 
twofold.  This  brings  the  wide  portion  of  the  astragalus  between 
the  malleoli,  and.  thus  insures  a  slot  wide  enough  for  free  motion 
of  the  astragalus  in  walking.  Secondly,  if  the  ankle-joint  should 
be  stiff,  the  patient  can  stand  with  his  heel  on  the  floor,  and  there- 
fore walk,  not  gracefully,  but  without  pain.  If  the  ankle  is  stiff 
in  an  extended  position,  equally  good  walking  is  impossible  except 
by  building  up  the  heel  of  the  shoe  on  the  affected  side,  and  the 
heel  and  sole  of  the  other  shoe. 

The  slight  inversion  of  the  foot  is  to  prevent  the  formation  of 
a  traumatic  flatfoot,  which  may  result  if  the  foot  is  everted.  This 
inversion  should  not  be  excessive. 

The  patient  may  go  about  on  crutches  from  the  start  in  cases 
without  displacement,  and  after  a  few  days  in  the  graver  injuries. 
The  injured  foot  should  be  kept  elevated  when  the  patient  is  sit- 
ting. After  the  first  week  the  lateral  splint  at  least  should  be 
removed  for  daily  bathing  and  massage.  This  will  add  greatly  to 
the  comfort  of  the  patient  and  hasten  the  recovery.  The  patient 
should  bear  some  weight  on  the  injured  limb  in  four  or  six 
weeks,  and  the  full  weight  in  from  six  to  eight  weeks.  There  are 
numerous  instances  of  recovery  delayed  beyond  these  periods,  in 
which  the  functions  were  ultimately  completely  restored. 

Fracture  of  the  Astragalus. — The  astragalus  is  broken  by 
falls  upon  the  feet,  especially  if  the  foot  is  sharply  flexed  against 
the  anterior  surface  of  the  tibia.  In  such  a  case  the  fracture  will 
probably  extend  through  the  neck  of  the  astragalus,  separating  the 


508  INJURIES   OF  THE   LEG   AND   FOOT 

head  from  the  body.  One-half  the  bone  may  then  be  dislocated 
from  its  normal  position. 

The  svmptoms  complained  of  are  pain  when  an  attempt  is 
made  to  move  the  foot  or  to  bear  any  weight  upon  the  heel.  If 
there  is  no  dislocation  of  a  fragment,  the  diagnosis  may  be  ex- 
tremely difficult.  It  is  desirable,  therefore,  to  make  radiographs 
of  both  feet  for  a  careful  comparison. 

Treatment  consists  in  reduction  of  the  fragments.  If  there 
is  marked  displacement,  reduction  can  seldom  be  effected  with- 
out an  operation.  If  the  deformity  is  slight,  the  limb  should 
be  immobilized,  with  the  foot  at  right  angle  to  the  leg  and  slightly 
inverted.  A  light  plaster  of  Paris  circular  bandage  from  the 
base  of  the  toes  nearly  to  the  knee  accomplishes  the  objects  of 
treatment  admirably.  In  a  few  days  this  should  be  split  down 
the  front,  removed  for  daily  massage  and  passive  motion,  and 
reapplied. 

Prognosis  depends  chiefly  upon  the  amount  of  displacement. 
If  this  is  slight,  a  normal  gait  may  be  regained  in  two  or  three 
months.  If  the  displacement  is  considerable,  the  function  of  the 
ankle-joint  is  likely  to  be  permanently  impaired.  If  reduction 
cannot  be  accomplished  by  manipulation,  the  displaced  fragment 
should  be  removed.  It  is  worth  remembering  that  good  function 
has  been  obtained  after  the  removal  of  even  the  whole  astragalus. 

Fracture  of  the  Os  Calcis. — -The  os  ealcis  is  broken  by 
falls  or  jumps  from  high  places,  the  patient  striking  squarely  upon 
his  heels.  One  or  both  bones  may  be  broken.  The  plane  of  frac- 
ture may  be  either  vertical  or  horizontal,  or  oblique,  or  irregular. 

The  chief  symptoms  complained  of  are  pain  and  an  inability 
to  bear  the  weight  on  the  heel.  Examination  will  show  a  distinct 
increased  bony  thickness  beneath  the  malleoli,  as  compared  with 
the  uninjured  side.  There  is  tenderness  on  pressure,  and  crepitus 
can  often  be  obtained  by  grasping  the  malleoli  with  one  hand  and 
manipulating  the  base  of  the  os  calcis;  or  the  anterior  portion 
of  the  bone  may  be  grasped  with  one  hand  and  the  posterior  por- 
tion manipulated  with  the  other.  In  some  cases,  when  the  acute 
swelling  has  subsided,  the  plantar  surface  of  the  heel  is  dis- 
tinctly nearer  the  tips  of  the  malleoli  than  on  the  uninjured  side. 

Treatment. — The  foot  should  be  placed  in  a  correct  position 
— that  is,  flexed  to  ninety  degrees  or  less,  and  slightly  inverted — 


AMPUTATIONS  509 

and  held  in  this  position  by  a  light  plaster  of  I'jiris  hand  ago 
extending  nearly  to  the  knee.  The  patient  should  go  about  on 
crutches,  without  touching  the  affected  limb  to  the  floor.  Xo  other 
treatment  is  necessary.  In  two  or  three  weeks  the  splint  should 
be  removed,  and  passive  and  active  motion  encouraged. 

The  pain  after  fracture  of  the  os  calcis  varies  greatly.  Some 
patients  suffer  little,  while  others  have  some  pain  upon  using  the 
foot  months  after  the  injury. 

If  fragments  of  the  os  calcis  are  badly  displaced,  they  should 
be  removed,  the  prognosis  after  operation  being  favorable.  The 
incision  may  be  made  on  either  side,  low  enough  down  to  avoid 
injury  to  the  vessels  and  nerves  and  tendons  which  pass  under  the 
malleoli. 

Fracture  of  the  Metatarsals. — Fracture  of  one  or  more 
of  the  metatarsal  bones  is  almost  always  due  to  direct  violence,  such 
as  the  passage  of  a  wheel  over  the  foot  or  the  fall  of  a  weight  upon 
it.  The  accompanying  swelling,  and  possibly  wounds  of  the  soft 
parts,  mask  the  fracture  of  the  bone,  but  such  a  fracture  can  usually 
be  made  out  by  careful  examination.  The  symptoms  are  swelling, 
ecchymosis,  and  pain.  The  pain  is  increased  by  pressure  against 
the  head  of  the  affected  metatarsal  as  well  as  by  pressure  directly 
upon  the  site  of  fracture.  If  the  head  of  the  bone  is  grasped  and 
manipulated,  pain  is  also  increased,  and  often  crepitus  is  produced. 
The  patient  can  usually  walk  by  bearing  his  weight  upon  his  heel. 
A  constricting  bandage,  either  of  adhesive  strips  or,  better,  of 
plaster  of  Paris,  extending  above  the  ankle,  will  give  the  patient 
considerable  relief.  Recovery  is  usually  complete  in  one  or  two 
months. 

Fracture  of  the  Phalanges. — The  bones  of  the  toes  are 
broken  as  the  result  of  direct  violence,  and  the  fracture  is  often 
a  compound  one.  The  usual  signs  are  present  and  are  easily 
elicited. 

Fracture  of  the  great  toe  can  be  treated  by  splints.  If  one 
of  the  other  toes  is  broken,  it  may  be  immobilized  and  deformity 
in  it  reduced  by  weaving  rubber  adhesive  strips  over  and  under 
the  toes  (Fig.  300,  p.  555). 

Amputations. — Most  of  the  amputations  of  the  lower  extrem- 
ity are  major  operations,  and  are  followed  by  rest  in  bed,  at  least 
until  the  flaps  have  united ;  but  as  compound  fractures  of  the  toes 


510  INJURIES   OF  THE  LEG    AM)    FOOT 

are  common  in  ambulant  practise,  a  few  words  as  to  minor  amputa- 
tions will  not  be  out  of  place.  What  has  been  said  on  amputation 
of  the  fingers  (p.  390)  is  true  for  amputations  of  the  toes.  They 
should  not  be  sacrificed  for  the  sake  of  immediate  appearance,  al- 
though it  is  often  well  to  lose  a  phalanx  to  gain  primary  union. 
However,  a  part  of  a  toe  has  nothing  like  the  value  of  a  part  of 
a  finger.  It  is  of  the  highest  importance,  however,  to  preserve  the 
whole  of  the  first  and  fifth  metatarsal  bones,  because  of  their  func- 
tion in  completing  the  arch  of  the  foot  and  because  of  the  muscular 
attachments  to  them.  If  the  great  toe  is  amputated,  the  tendon 
of  the  long  flexor  should  be  firmly  sutured  in  the  attachments  of 
the  short  flexors  to  the  metatarsal.  If  there  is  plenty  of  skin  for 
the  flaps  the  suture  line  should  he  kept  away  from  the  plantar 
surface  of  the  toe  by  making  a  large  plantar  flap.  In  amputation 
through  the  metatarsophalangeal  joint  an  oval  incision  may  be 
chosen,  or  a  long  plantar  flap  may  be  sutured  to  a  short  dorsal  flap. 


CHAPTER    XVIII 


INFLAMMATIONS    OF  THE    LEG    AND    FOOT 


EFFECTS   OF   HEAT   AND   COLD 

Frost-bite. — Slight  exposures  of  the  limbs  of  healthy  persons 
to  cold  produce  only  temporary  discomfort.  Anemic  and  ill  nour- 
ished individuals  suffer  from  subsequent  pain  and  burning  of  the 
exposed  parts  called  chilblains.  Prophylactic  treatment  consists 
in  the  administration  of  iron  and  other  tonics,  in  the  wearing  of 
warm  loose  clothing,  in  the  improvement  of  local  circulation  by 
cold  bathing,  etc. 


Fig.  272. — Frost-bite  of  Both  Feet,  Three  Weeks  after  Injury,  Showing  a 
Zone  of  Slight  Injury  with  Loss  of  Epithelium  (Now  Restored),  a  Zone 
of  Deeper  Injury  with  Loss  of  the  Whole  Skin  (Now  a  Granulating 
Area),  and  a  Zone  of  Total  Gangrene.    Patient  a  woman  aged  fifty-six  years. 

511 


112 


INFLAMMATIONS   OF  THE   LEG    AND   FOOT 


When  any  pari  of  the  body  has  been  chilled  or  frozen  its 
temperature  should  be  very  gradually  raised  to  normal.  The 
more  severe  the  frost,  the  greater  the  importance  of  this  rule. 
Hence  it  is  generally  understood  that  a  limb  which  is  frozen 
polid  should  be  thawed  out  by  rubbing  with  ice  or  snow,  or 
by  immersion  in  ice-water.  Even  in  less  severe  cases  the  per- 
son should  keep  away  from  the  fire  on  entering  the  house,  and 
should  bathe  the  affected  part  with  cold  water.  Painful  spots  may 
be  painted  with  tincture  of  iodine. 

The  importance  of  conservative  treatment  in  the  severer  de- 
crees of  frost-bite  lias  been  emphasized  on  page  397.  The  accom- 
panying illustrations  (  Fig.  i'Ti'  and  Fig.  273)  show  most  graph- 
ically how  much  may  be- gained  by  delay.  The  new  growth  of 
epithelium  and  granulations  made  it  possible  to  amputate  less 
tissue  and  still  gain  union  of  the  flaps.  All  of  the  tarsal  bones 
were  preserved  in  the  right  foot,   while  in  the  left  foot   it  was 


Fig.  273. — Frost-bite  of  Both  Feet  Showing  the  Results  after  Delayed  Am- 
putation.    The  patient  (same  subject  as  Fig.  272)  walks  easily  without  a  cane. 


necessary  to  remove  the  cuneiforms.  The  patient  notices  a  dis- 
tinct difference  in  the  stability  of  the  two  feet  on  this  account. 
At  the  time  of  the  amputation  even  these  flaps  were  not  entirely 


GANGRENE 


513 


covered  with  epithelium.  The  deeper  tissues  united  promptly, 
but  the  granulating  areas  required  many  weeks  to  become  covered 
by  epithelium,  in  part  derived 
from  skin-grafts,  and  in  part 
from  lateral  growth  from  the 
existing  epithelium.  This  is, 
however,  time  well  spent,  since 
the  useful  feet  obtained  are  far 
superior  to  the  stumps  remain- 
ing after  a  Syme's  or  even  a 
Chopart's  amputation.  Com- 
pare what  is  said  below,  in  the 
paragraphs  on  gangrene. 

Burns. — The  dorsum  of  the 
foot  is  often  burned  by  hot  wa- 
ter, etc.,  spilled  upon  it.  More 
serious  burns  of  the  lower  ex- 
tremity are  due  to  the  skirts 
catching  fire.  The  burns  in 
such  cases  are  most  severe  on 
the  posterior  surface  from  the 
knee  to  the  hip  (Fig.  274). 

Directions  for  the  treatment 
of  burns  are  given  on  page  26. 

Gangrene. — For  clinical 
purposes  cases  of  gangrene  of 
the  toes  or  foot  should  be  di- 
vided into  two  classes:  In  one 
class  the  cause  is  external — a 
crush,    a    burn,    carbolic    acid, 

frost-bite,  etc.,  and  is  usually  not  repeated.  In  the  other  class 
the  cause  is  internal — endarteritis,  diabetes,  Raynaud's  disease, 
etc.  In  this  class  the  cause  is  more  or  less  continuous.  In  the 
first  class  palliative  treatment  should  be  carried  out  until  the  line 
of  demarcation  is  well  established.  The  superficial  gangrene  in 
these  cases  is  almost  always  more  extensive  than  the  deeper  gan- 
grene, so  that  by  delay  good  flaps  may  be  obtained  for  a  lesser 
amputation  than  at  first  appeared  possible  (Fig.  275). 

The  reverse  is  often  true  in  gangrene  due  to  a  constitutional 


Fig.  274. — Burns  of  the  Back  of  the 
Leg  and  Thigh  of  a  Child  Caused 
by  Clothing  Catching  Fire.  Pho- 
tograph four  weeks  after  injury. 
Note  that  a  few  deep  groups  of  epi- 
thelial cells  have  escaped  injury,  and 
have  grown  up  so  as  to  form  islands 
in  the  granulating  area. 


514 


INFLAMMATIONS   OF   THE    LEG    AND   FOOT 


disorder.  Then  one  has  to  do  with  a  condition  which  tends  to 
progress.  Hence  amputation  should  not  be  too  long  delayed,  and 
when  performed,  it  should  be  a1  a  sufficiently  high  level  not  only 

t<>  insure  union  of  the 
flaps,  but  to  render  im- 
probable a  recurrence 
of  the  gangrene  within 
a  short  time. 

The  early  manifes- 
tation of  gangrene  from 
an  internal  cause  is  a 
venous  congestion, 
sometimes  accompanied 
with  blisters  extending 
part  way  from  the  toes 
to  the  ankle,  and  usu- 
ally a  little  higher  on 
the  inner  than  the  out- 
er side  of  the  foot.  In 
this  early  stage  of  the 
trouble  hot  and  cold 
bathing,  rubbing,  ele- 
vation of  the  foot  from 

Fig.    275.  —  Gangrene    of  Toe,     Possibly    from       time  to  time  during  the 
Frost-bite  ;     no      Diabetes.       Duration     one        -i  -,  • 

month.     Patient  a  man  aged  fifty-two  years.  ^aJ>     anc*    most    impor- 

tant of  all,  a  dry  dress- 
ing of  cotton  to  prevent  loss  of  heat,  will  generally  postpone  the 
gangrene  for  a  considerable  time,  perhaps  for  months  or  even 
years,  if  the  general  state  of  health  can  be  improved.  The 
skin  under  such  circumstances  is  easily  destroyed.  One  should 
avoid  the  use  of  counter-irritants,  as  intractable  ulcers  may 
easily  be  produced  by  them. 


ACUTE   INFLAMMATIONS 

"While  in  the  upper  extremity  the  hand  is  especially  exposed 
to  injury,  the  foot  is  protected  by  the  shoe,  so  that  contusions  and 
wounds  of  the  lower  extremity  are  oftenest  met  with  in  the  shin, 
and,  owing  to  poor  circulation,  lesions  at  first  slight  may  become 


PHLEBITIS  AND  THROMBOSIS  515 

serious.  Tims  a  small  cut  or  scratch  may  develop  into  an  annoy 
ing  ulcer  iu  individuals  whose  general  health  is  good,  while  in 
those  in  whom  there  coexists  chronic  systemic  trouble  or  eczema, 
edema,  or  varicose  veins,  destructive  inflammations  are  even  more 
common.  These  differences  result  chiefly  from  the  poorer  circula- 
tion in  the  dependent  extremity;  partly  from  the  fact  that  the 
parts  injured  in  the  two  extremities  do  not  usually  correspond. 
Thus  it  is  the  hand  which  is  most  often  injured  in  the  upper 
extremity,  and  the  leg  in  the  lower.  Infected  wounds  of  the 
forearm  behave  more  nearly  as  do  those  of  the  leg  in  forming 
local  cellulitis  and  abscess.  These  remarks  apply  only  to  acute 
infections.  Syphilis  and  tuberculosis  have  their  own  methods  of 
tissue  destruction,  so  that  the  lesions  of  such  diseases  vary  little 
whether  in  the  arm  or  leg. 

Cellulitis. — Cellulitis  in  the  lower  extremity  is  apt  to  be  ac- 
companied by  an  unusual  amount  of  edema  on  account  of  the 
poorer  circulation  in  this  part  of  the  body.  The  same  may  have 
existed  before  the  injury  or  it  may  be  wholly  due  to  the  infection, 
a  point  which  can  be  settled  by  comparing  the  two  limbs.  To  over- 
come the  edema  the  patient  should  lie  down  most  of  the  time,  or 
sit  with  the  affected  limb  in  a  horizontal  position.  A  wet  dress- 
ing is  cooling  and  assists  in  overcoming  the  infection.  It  is  bet- 
ter not  to  prevent  evaporation  by  rubber  tissue,  but  to  keep  the 
gauze  wet  by  pouring  water  on  it  every  hour  or  so.  For  the 
further  treatment  of  cellulitis  see  page  35.  Abscess  should  be 
watched  for,  and  opened  early.  A  large  hypodermic  needle  is  a 
most  satisfactory  means  of  making  an  early  diagnosis  of  abscess. 

Lymphangitis. — A  superficial  lymphangitis  with  reddened 
vessels  traceable  as  far  as  the  glands  in  the  groin,  and  correspond- 
ing to  that  which  so  often  occurs  in  the  upper  extremity,  is  seldom 
seen.  A  deeper  lymphangitis,  following  the  veins,  and  often  asso- 
ciated with  phlebitis  and  thrombosis,  is  of  more  frequent  occur- 
rence. It  is  a  serious  malady,  and  by  extension  upward  into  the 
vena  cava,  or  by  embolism,  or  simply  by  the  intensity  of  the  septic 
process  it  may  cost  the  patient  his  life.  In  view  of  this  fact  every 
patient  who  has  a  deep  lymphangitis  of  the  leg  should  be  treated 
in  bed  from  the  time  the  diagnosis  is  made. 

Phlebitis  and  Thrombosis. — Phlebitis  or  inflammation  of 
a  vein  may  develop  in  a  varicose  vein  (p.  538),  and  run  the  course 
35 


516  INFLAMMATIONS   OF  THE   LEG   AND   FOOT 

of  an  acute  inflammation  without  suppuration,  or  it  may  be  accom- 
panied by  suppuration,  though  uo  visible  source  of  infection  be 
present.  The  first  symptoms  of  phlebitis  are  pain,  heat,  redness, 
and  swelling  over  an  area  an  inch  broad  and  which  is  more  or 
less  Jong,  according  to  the  extent  of  the  inflamed  vein.  The  vein 
itself  can  usually  be  felt  as  a  tender  indurated  cord  in  the  center 
of  this  area.  If  thrombosis  takes  place  in  the  vein,  the  hardness 
of  the  vessel  is  more  marked,  and  persists  after  the  tenderness 
and  surrounding  swelling  have  subsided. 

The  phlebitis  may  gradually  subside  without  extending  fur- 
ther, but  it  usually  extends  upward  either  in  continuity  or  skip- 
ping a  few  inches  of  the  vein  the  process  will  repeat  itself  further 
up.  Thus  a  patch  of  phlebitis  in  the  calf  of  the  leg  may  be  fol- 
lowed by  another  in  the  thigh,  the  intervening  veins  remaining 
normal.     Usually,  however,  it  spreads  by  continuity. 

Treatment. — In  the  first  days  phlebitis  should  be  treated  by 
rest  in  bed  and  an  ice-bag.  When  the  acute  pain  has  subsided, 
unguentum  ichthyol  and  a  firm  bandage  make  a  good  dressing. 
The  limb  should  be  bathed  and  moved  with  caution,  even  after 
the  acute  symptoms  have  passed  over.  Massage  is  contraindi- 
cated.  One  does  not  wish  to  break  up  a  thrombus  and  send  its 
fragments  into  the  blood-current. 

If  the  patch  of  phlebitis  is  small,  a  patient  may  absolutely 
refuse  to  go  to  bed.  His  leg  should  then  be  treated  with  unguen- 
tum ichthyol  and  a  firm  bandage,  and  he  should  keep  as  quiet 
as  possible.  The  danger  in  such  a  case  is  that  the  thrombus  may 
extend  upward,  or  that  a  portion  being  detached  may  form  a  fatal 
embolus.  Still  embolism  is  a  very  rare  accident  in  thrombosis  of 
the  veins  of  the  leg  or  thigh. 

Suppuration  may  occur  at  any  time  in  the  history  of  a  throm- 
bus, even  without  any  visible  break  in  the  skin.  If  an  abscess 
forms,  it  should  be  opened.  If  it  is  of  a  sluggish  character  a  short 
incision  will  suffice. 

Resection  of  the  affected  vein  has  been  advocated  recently  as 
a  means  of  quicker  recovery  (ten  days  to  two  weeks)  in  non-sup- 
purative  cases.  This  is  a  heroic  remedy  for  a  disease  which  is 
often  very  mild;  but  it  is  especially  suited  to  cases  in  which  the 
varicose  veins  require  removal  irrespective  of  the  acute  inflam- 
mation. 


ABSCESS 


517 


Lymphadenitis. — The  femoral  or  inguinal  glands  may  be- 
come inflamed  from  an  infected  wound  of  the  leg  or  foot.  Search 
will  usually  reveal  the  entrance  of  the  infection.  If  the  wound 
is  treated  properly,  the  swelling  of  the  lymph-glands  usually  sub- 
sides. If  the  glands  suppurate,  the  pus  must  be  evacuated.  Re- 
moval of  the  affected  gland  should  be  performed  when  possible,  as 
the  healing  afterward  is  more  prompt  than  when  the  gland  is 
merely  incised.  (Compare  p.  431.)  The  incision  for  either  oper- 
ation should  be  strictly  longitudinal  to  avoid  injury  of  the  nerves 
and  vessels  of  the  groin.  The  removal  of  a  lymph-gland  is  always 
a  more  difficult  procedure  than  the  previous  examination  of  the 
parts  would  indicate. 
The  gland  is  so  readily 
palpable  that  one  is 
apt  to  forget  that  the 
very  fact  that  it  ele- 
vates the  skin  also  in- 
dicates that  the  under 
surface  of  the  gland  is 
deeply  embedded  in  the 
tissues.  Hence  the  pa- 
tient should  be  given 
a  general  anesthetic 
before  any  attempt  is 
made  to  remove  the 
gland,  especially  if  if 
is  inflamed. 

Abscess. — Super- 
ficial abscess  in  the 
thigh  or  leg  may  fol- 
low a  contused  or  lac- 
erated wound,  or  it 
may  develop  from  a 
small  scratch  or  from 
the  bite  of  an  insect 
(Fig.  276).  It  is  usu- 
ally associated  with 
much  edema  and  cellulitis,  so  that  the  presence  of  pus  is  not 
always  easy  to  make  out.    In  doubtful  cases,  if  there  is  considerable 


Fig.  276. — Abscess  in  Front  of  the  Knee  from 
an  Infection  on  the  Shin.  Patient  a  girl,  one 
year  old. 


518 


INFLAMMATIONS   OF   THE   LEG   AND   FOOT 


pain,  and  particularly  if  the  process  is  extending  in  spite  of  a  wet 
dressing  and  resl  to  the  liml>,  an  incision  should  be  made.  A  quan- 
tity of  serum  will  escape  and  relieve  the  tension,  even  if  no  pus  is 
found.  If  phlebitis  can  be  ruled  out  cellulitis  in  the  leg  will  gen- 
erally be  found  to  have  a  purulent  center.     (See  p.  515.) 

Suppuration  about  the  knee  in  the  form  of  small  boils  may 
keep  up  for  a  long  time,  reinfection  taking  place  in  a  most  pro- 
voking manner. 

A_bscess  in  the  foot  may  arise  from  a  punctured  wound  made 
by  a  wire  nail  or  sliver  and  from  injudicious  paring  of  a  corn  or 
callus.  If  the  vicinity  of  such  a  wound  is  swollen  and  tender  it 
should  be  incised  and  drained.  (Compare  punctured  wound  of 
tinger,  p.   331.)     If  the   punctured  wound  is  in  the  ball  of  the 

foot,  the  pus  often  col- 
lects dorsally  and  should 
then  be  evacuated  by  a 
dorsal  incision,  either 
with  or  without  a  plan- 
tar incision  through  the 
original  wound.  It  is  not 
necessary  to  connect  these 
two  incisions ;  each  can 
be  treated  from  its  own 
surface  of  the  foot. 

Infected  Insect- 
bites — Vagabond's 
Disease. — The  bites  of 
the  body  louse,  insignifi- 
cant in  themselves,  cause 
an  intense  itching,  to  re- 
lieve which  the  patient 
scratches  the  skin  violent- 
ly, making  deep  abra- 
sions. In  a  healthy  per- 
son with  a  clean  skin  in- 
fection would  not  be  like- 
ly to  result;  but  the  per- 
sons infested  with  body  lice  are  usually  impoverished  individuals, 
often  weakened  by  sickness  or  alcoholism,  or  lack  of  food,  and 


Fig.  277. — Ulcers  of  the  Leg,  Two  Weeks, 
from  Pediculosis  and  Scratching.  Pa- 
tient a  boy  aged  sixteen  years. 


CHRONIC    ULCER   OF  THE   LLC 


519 


unable  to  bathe  frequently.  Hence  the  scratches  often  ulcerate — 
especially  those  made  upon  the  back  and  legs  (Fig.  277).  The 
appearances  are  so  uniform  that  the  condition  is  often  spoken  of 
as  Vagabond's  Disease. 

Treatment  consists  in  the  removal  and  disinfection  of  the 
clothing  by  boiling  or  otherwise,  bathing  the  patient,  and  the  use 
of  some  antipruritic  lotion  or  salve  to  control  the  itching,  which 
often  lasts  long  after  the  insects  have  ceased  to  bite.  Shallow  ulcers 
generally  heal  promptly ;  the  deeper  ones  should  be  treated  accord- 
ing to  principles  laid  down  in  the  following  pages. 

Eczema. — Eczema  of  the  leg  is  of  interest  to  the  surgeon  be- 
cause it  so  frequently  precedes  and  accompanies  chronic  ulcer.  It 
is  usually  of  the  dry  papular  form,  but  a  weeping  eczema  is  occa- 
sionally seen  in  connection  with  ulcer  of  the  leg,  forming  a  com- 
bination of  lesions  which  tries  the  skill  of  the  doctor  severely. 
The  eczema  causes  itch- 
ing, the  itching  causes 
scratching,  the  scratch- 
ing causes  ulceration, 
the  ulceration  causes 
discharge  which  irri- 
tates the  skin  and  in- 
creases the  eczema. 
Such  conditions,  if 
neglected  in  ill  nour- 
ished individuals,  may 
easily  lead  to  chronic 
ulceration. 

The  treatment  of 
eczema  is  given  on  page 
57.  Its  treatment, 
when  combined  with  ul- 
cer of  the  leg,  is  given 
on  page  524. 

Chronic  Ulcer  of 
the  Leg. — Both  on  ac- 
count   of    its    frequent 


Fig.  278.- 


-Ulcek   of  the   Leg  Occurring  in  a 
Man  Aged  Forty  Years. 


occurrence  among  working  people,  and  still  more  because  of  its 
duration,  chronic  ulcer  is  by  far  the  commonest  lesion  seen  in  a 


520  INFLAMMATIONS   OF  THE   LEG  AND   FOOT 

surgical  dispensary  (Fig.  278).     Some  ulcers  can  be  cured  in  a 

few  weeks,  in  other  eases  mouths  of  the  most  faithful  treatment 
must  elapse  before  the  epithelium  can  be  coaxed  over  the  granu- 
lating area.  In  these  difficult  cases  a  single  ill  chosen  dressing, 
or  a  failure  of  the  patient  to  come  for  treatment  for  a  few  days, 
or  an  alcoholic  debauch,  may  wipe  out  the  gain  of  weeks.  In 
dealing  with  a  problem  of  this  character  it  is  evident  that  a  change 
of  doctors,  or  carelessness  on  the  part  of  the  patient,  must  mate- 


Fig.  279. — Chronic  Ulcer  Almost  Surrounding  Leg. 

rially  interfere  with  the  success  of  treatment.  Hence  there  are 
instances  of  patients  who  have  come  to  be  treated  for  an  ulcer  of 
the  leg,  more  or  less  continuously  for  many  years.  Probably  most 
of  these  patients  could  be  cured  if  they  could  be  regularly  treated 
by  the  same  surgeon  for  a  period  of  six  or  eight  months  (Fig. 
279). 

It  is  at  least  the  opinion  of  the  writer  after  dressing  hundreds 
of  these  ulcers  for  weeks  together  that  they  can  all  be  healed  by 
local  ambulant  treatment  if  they  are  due  solely  to  local  causes. 
There  are  a  few  ulcers  due  to  constitutional  causes  in  which  local 
treatment  has  no  effect,  but  these  are  rare  exceptions. 

Predisposing  Causes. — The  constitutional  disorders  predis- 
posing to  chronic  ulcer  of  the  leg  are  alcoholism,  anemia,  diabetes, 
syphilis,   and  any  trouble  such  as  cardiac  or  nephritic  disease, 


CHRONIC   ULCER   OF  THE   LEG  521 

which  causes  chronic  edema,  and  any  disease  of  the  nervous  sys- 
tem which  affects  the  nutrition  of  the  skin.  Endarteritis,  dia- 
betes, and  some  nervous  affections  produce  degenerative  processes 
in  the  toes  and  feet  rather  than  ulcers  of  the  leg. 

The  local  conditions  which  favor  chronic  ulcer  of  the  leg  are 
eczema,  edema,  dermatitis,  and  varicose  veins. 

Eczema  is  a  prominent  factor  in  many  cases,  and  of  secondary 
importance  in  others.  It  causes  the  patient  to  rub  and  scratch 
the  leg  and  thus  form  new  ulcers. 

Edema  may  be  soft  and  easily  compressible,  disappearing  at 
night  when  the  patient  lies  down,  and  reappearing  after  he  has 
been  for  some  hours  on  his  feet.  It  may  also  be  of  a  chronic 
type,  almost  as  hard  as  a  board,  seriously  interfering  with  the 
local  circulation. 

Dermatitis  is  usually  seen  only  in  the  early  stages  of  an  ulcer, 
or  after  neglect,  or  very  bad  treatment. 

Varicose  veins  are  often  spoken  of  as  though  they  were  the 
sole  cause  of  a  chronic  ulcer.  Hence  the  name  "  varicose  ulcer." 
This  is  an  erroneous  idea,  as  varicose  veins  are  only  one  factor  in 
chronic  ulcer;  and  a  chronic  ulcer  which  depends  chiefly  on  vari- 
cose veins  for  its  existence  is  one  of  the  easiest  kind  to  heal,  be- 
cause the  dilatation  of  the  veins  can  be  so  readily  counteracted 
by  a  well  fitting  bandage.  The  term  "  varicose  ulcer,"  as  applied 
indiscriminately  to  chronic  ulcer  of  the  leg  is  therefore  mislead- 
ing and  should  be  given  up. 

Etiology. — The  immediate  cause  of  an  ulcer  of  the  leg  is  usu- 
ally a  traumatism,  such  as  a  blow  on  the  shin  or  a  scratch  of  the 
finger-nails.  Occasionally  the  traumatism  may  be  so  slight  that 
the  patient  cannot  explain  the  beginning  of  the  ulceration ;  or  the 
start  may  be  in  the  spontaneous  rupture  of  a  dilated  vein.  Wrong 
applications  or  infection  of  the  scratch  spread  the  necrosis  of 
the  skin  and  an  ulcer  is  started,  which  in  a  few  days  may  destroy 
skin  that  can  be  restored  only  by  careful  treatment  of  several 
weeks'  duration  (Fig.  280).  It  may  fairly  be  called  a  chronic 
ulcer  therefore,  even  from  the  beginning. 

Treatment. — It  is  obvious  that  an  ulcer  which  is  largely  due 
to  unfavorable  circulatory  conditions  is  more  easily  handled  if 
the  patient  can  lie  up  in  bed.  This  should  be  the  first  advice  to 
those  who  can  afford  to  follow  it.     Unfortunately  most  patients 


OL'J 


INFLAMMATIONS   OF   THE    LEG    AND   FOOT 


cannot  afford  the  time  for  this;  so  that  the  problem  before  the 
surgeon  is,  in  most  cases,  bow  to  repair  the  leg  while  the  patient 
is  walking  about  all  day,  or  worse  vet,  is  standing  at  a  wash- 
tub  or  bench.      Let  him  console  himself  with  the  thought  that  an 

ulcer  healed  under 
these  conditions  will 
be  likely  to  renin  in 
healed  with  reason- 
able care,  while  one 
healed  in  bed  may 
easily  break  down 
when  the  patient  goes 
about,  unless  the 
patient  is  especially 
careful  to  guard 
against  the  change 
in  circulation  when 
he  leaves  the  bed. 
This  is  one  reason 
why  ulcers  closed  by 
skin  grafts  are  so  apt 
to  break  down  again. 
Since  so  many 
factors  may  contrib- 
ute to  keep  a  chronic 
ulcer  of  the  leg  from 
healing,  it  is  plain 
that  the  treatment 
must  be  different  not 


Fig.  280. — Ulcer  of  Leg  two  Weeks  from  Scratch; 
Spread  by  Vaseline  Dressing.  Patient  a  man 
aged  thirty-three  years. 


only  for  different  patients,  but  also  for  any  given  patient,  ac- 
cording to  the  appearance  of  the  ulcer.  "When  a  single  remedy 
is  advocated  as  a  sure  cure  for  all  ulcers,  it  is  evident  that  the 
experience  of  its  advocate  is  limited,  or  else  bis  observation  is 
careless.  The  measures  here  given  are  intended  to  combat  one 
or  more  of  the  conditions  which  retard  recovery.  They  should 
be  combined  in  a  way  to  meet  the  symptoms  which  exist.  "When 
one  measure  has  been  used  for  a  week  or  so  with  good  effect,  and 
then  its  influence  wanes,  continued  improvement  may  follow  a 
change  to  another  agent  of  the  same  class. 


CHRONIC   ULCER  OF   THE  LEG  523 

1.  Measures  to  Overcome  Anemia  and  Chronic  Edema. — A 
daily  hot  bath  of  the  foot  and  leg  for  twenty  minutes  will  stimulate 
circulation,  and  in  a  few  days  soften  and  reduce  an  old  hard 
edema.  Besides  it  cleanses  the  surrounding  skin,  lessens  the 
itching,  and  thus  reduces  the  tendency  of  the  patient  to  scratch 
the  leg.  Kubbing  the  leg  with  a  cotton  swab  saturated  with  crude 
petroleum  will  remove  discharges  and  crusts,  will  soften  the  skin 
and  reduce  edema,  will  alleviate  itching,  and  will  not  increase 
any  existing  eczema. 

2.  Measures  to  Cleanse  the  Ulcer. — The  ulcerating  surface 
may  be  wiped  with  a  cotton  swab  soaked  with  any  mild  antiseptic 
solution.  If  hydrogen  peroxid  is  used,  it  should  be  diluted  with 
four  or  eight  parts  of  water.  Many  ulcers  are  extremely  tender 
when  treatment  is  first  begun,  and  strong  peroxid  causes  sharp 
burning  pain.  If  there  is  a  tendency  to  eczema  one  should  be 
extremely  careful  to  avoid  the  application  of  irritating  solutions 
even  for  cleansing.  A  swab  soaked  in  crude  petroleum  is  a  good 
thing  to  cleanse  such  skin. 

3.  Measures  to  Allay  Acute  Inflammation. — If  the  skin  and 
subcutaneous  tissues  about  the  ulcer  are  inflamed,  it  is  a  good 
plan,  to  soak  the  foot  and  leg  daily  for  twenty  minutes  or  more 
in  a  pail  of  hot  carbolic  solution  (1 :  120),  and  to  apply  compresses 
wet  with  carbolic  acid  in  1 :  100  solution,  or  creolin  in  1 :  200 
solution,  or  corrosive  sublimate  1 :  2,000  solution,  or  aluminum 
acetate  in  1 :  25  solution.  The  limb  should  be  bandaged  with  a 
gauze  bandage,  and  the  dressing  kept  constantly  moist  by  cold 
water  poured  on  the  outside  of  the  bandage  every  hour  or  two. 
]STo  gutta-percha  or  other  impervious  material  should  be  wrapped 
about  the  leg.  An  outside  piece  of  flannel  may  be  used  to  keep 
up  the  warmth  if  the  leg  feels  cold.  This  dressing  is  more  suitable 
for  warm  weather  than  for  cold. 

4.  Measures  to  Stimidate  Granulations. — -Eight  or  twelve 
thicknesses  of  gauze,  cut  so  as  to  overlap  the  ulcer  on  all  sides 
by  a  half-inch,  and  saturated  with  red  wash  (zinc  sulphate,  gr.  x ; 
compound  tincture  of  lavender,  Tl\xv,  water  oiv),  may  be  kept 
moist  by  additions  of  water,  or  by  the  application  over  it  of  a 
large  compress  thickly  spread  with  Lassar's  paste  or  any  thick 
salve  nonirritating  to  the  surrounding  skin.  This  will  keep  the 
astringent  gauze  moist  for  two  days,  and  does  not  sweat  the  under- 


524  INFLAMMATIONS  OF  THE  LEG  AND  FOOT 

lying  skin,  as  does  rubber  tissue.  Other  solutions,  such  as  creolin, 
1:200,  or  nitrate  of  silver,  1:100  or  1:200,  may  be  used  to 
saturate  the  inner  gauze. 

Another  I'lan  is  to  apply  to  the  ulcer  gauze  saturated  with 
balsam,  of  Peru,  pure  or  mixed  with  oil.  This  balsam  gauze 
requires  no  protective  covering,  as  it  does  not  quickly  dry  out. 

The  granulations  are  even  more  powerfully  stimulated  by 
dusting  the  ulcer  thickly  with  granular  naphthalin  before  apply- 
ing the  wet  gauze.     This  powder  is  antiseptic  and  does  not  cake. 

5.  Measures  to  Promote  the  Growth  of  Epithelium. — Epi- 
thelium will  grow  rapidly  in  moisture  and  warmth,  provided  there 
is  freedom  from  irritating  discharges,  a  good  circulation,  and 
granulations  which  are  as  nearly  as  possible  on  a  level  with  the 
skin.  The  measures  already  described  in  paragraphs  1,  2,  3,  and  4 
are  calculated  to  assist  therefore  in  promoting  the  growth  of  epi- 
thelium. Exuberant  granulations  are  rarely  seen  in  chronic 
ulcers  of  the  leg.  If  they  occur  they  should  be  burned  lightly  by 
touching  them  in  spots  with  a  pencil  of  silver  nitrate,  which 
should  in  no  case  be  applied  within  one-fourth  of  an  inch  of  the 
skin  margin,  since  the  caustic  action  spreads  somewhat  beyond 
the  area  touched.  Under  the  most  favorable  conditions  epithelium 
can  hardly  be  made  to  grow  in  the  leg  at  a  faster  rate  than  one- 
eighth  of  an  inch  a  week.  This  would  give  a  month  as  the  shortest 
possible  time  for  the  healing  of  an  ulcer  of  the  leg  one  inch  across, 
provided  the  ulcer  involves  the  whole  thickness  of  the  skin,  so  that 
no  islands  of  epithelium  may  grow  up  in  the  center  of  the  ulcer. 

Occasionally  it  happens  that  granulations  grow  up  in  little 
tufts  and  become  covered  with  epithelium  (Fig.  281).  This  gives 
a  pebbly  appearance  to  the  scar  which  can  still  be  seen  even  after 
the  epithelium  has  become  of  normal  thickness.  Such  an  ulcer  is 
usually  very  painful  until  entirely  healed. 

6.  Measures  to  Overcome  Itching  and  Eczema. — Mild  dry 
eczema  is  sufficiently  treated  by  the  measures  mentioned  under 
paragraphs  3  and  4.  Eor  excessive  itching  nothing  is  better  than 
sponging  with  a  solution  of  carbolic  acid,  1 :  20.  If  the  eczema  is 
the  chief  feature,  it  may  be  treated  by  cleansing  with  crude  petro- 
leum, dusting  freely  with  lycopodium,  and  covering  with  com- 
presses soaked  in  crude  petroleum ;  or  compresses  soaked  with 
aluminum  acetate  solution,  1:25,  may  be  applied  and  kept  con- 


CHRONIC  ULCER  OF   THE  LEG 


525 


stantly  wet  with  water ;  or  other  measures  suitable  to  the  treatment 
of  eczema  elsewhere  in  the  body  may  be  employed. 

Eczema  occuring  at  the  junction  of  the  skin  of  the  sole  and 
that  of  the  dorsum  of  the  foot  leads  to  ulceration  that  is  very  slow 


Fig.  281. — Chronic  Ulcer  of  Leg  with  Proliferation,  Giving  it  a  Pebblt  Ap- 
pearance even  when  Healed.     Patient  a  woman  aged  sixty-three  years. 

to  heal.     Therefore  one  should  be  very  exact  with  the  early  treat- 
ment.    Compare  perforating  ulcer,  page  529. 

7.  Measures  to  Reduce  Venous  Engorgement  and  Edema. — In 
all  cases  in  which  edema  or  venous  engorgement  is  present, 
whether  or  not  large  varicose  veins  are  prominent,  elastic  bandag- 
ing is  of  great  importance.  While  the  ulcer  is  still  open,  a  rub- 
ber bandage  or  stocking  is  not  permissible.     Elastic  compression 


526  INFLAMMATIONS    OF   THE   LEG    AND    FOOT 

may  be  applied  outside  of  the  dressing  selected,  by  means  of  an 
even  layer  of  non-absorbent  cotton  and  a  cotton  bandage  or  by  a 
flannel  bandage  or  a  stockinet  bandage.  In  any  case  the  bandage 
should  begin  at  the  base  of  the  toes  and  extend  above  the  calf,  omit- 
ting the  heel  unless  the  ulcer  is  situated  below  a  malleolus.  The 
successful  application  of  a  bandage  of  this  sort  requires  consid- 
erable practise.  The  test  of  a  good  bandage  is  not  in  the  pattern 
made  by  its  turns,  but  in  the  smoothness  with  which  they  lie  one 
ever  the  ether,  felt  by  passing  the  band  down  the  back  of  the 
leg  after  the  bandage  is  complete.  If  all  the  turns  press  evenly 
the  bandage  will  remain  in  place,  even  though  the  patient  is  con- 
stantly walking  about,  and  when  removed  there  will  be  no  ridges 
in  the  edematous  leg  to  indicate  where  one  edge  of  the  bandage  was 
drawn  tighter  than  the  other.  The  best  type  of  bandage  to  apply 
is  shown  in  Figure  39 G,  page  674. 

8.  General  Measures  to  be  Observed  During  the  Healing  of 
an  Ulcer. — Any  habit  of  the  patient  or  constitutional  condition 
that  exerts  an  unfavorable  influence  on  nutrition  and  repair 
should  be  corrected  if  possible.  The  patient  is  better  without 
much  alcohol,  tobacco,  or  tea.  Constipation  often  needs  to  be 
corrected.  Circular  garters  have  been  severely  criticized,  but 
probably  have  little  effect  in  producing  varicose  veins.  If  possi- 
ble, the  patient  should  rest  for  an  hour  or  two  a  day  in  a  hori- 
zontal position.  At  least  he  can  make  a  practise  of  putting  the 
affected  leg  upon  another  chair  Avhenever  he  sits  down.  If  there 
is  good  reason  to  believe  that  an  ulcer  is  syphilitic  (Fig.  282), 
mercury  and  iodid  of  potash  should  be  administered.  It  is  a  mis- 
take, however,  to  infer  that  every  chronic  ulcer  occurring  in  a  pa- 
tient who  has  had  syphilis  at  some  period  of  his  life  is  syphilitic. 

9.  Measures  to  Prevent  the  Recurrence  of  an  Ulcer. — A  large 
proportion  of  the  chronic  ulcers  seen  in  a  surgical  clinic  are  recur- 
rent. They  have  been  healed  once  or  many  times,  have  remained 
so  for  Aveeks  or  months,  and  usually  on  account  of  the  neglect  of 
the  patient,  the  skin  in  or  near  the  site  of  the  old  ulcer  has  broken 
down,  and  a  minute  ulcer  forms.  Sometimes  the  patient  has  the 
good  sense  to  come  immediately  for  treatment;  usually  he  treats 
it  at  home  with  lard  or  vaseline,  or  worst  of  all  carbolic  salve,  and 
the  ulcer  rapidly  increases  in  size  and  is  an  inch  or  more  in  diam- 
eter when  first  seen  by  the  surgeon. 


CHRONIC   ULCER   OF  THE   LEO 


527 


This  sad  relapse  can  usually  be  avoided  if  the  patient  will, 
firstly,  bathe  the  healed  leg  daily  or  at  least  twice  a  week  with 
soap  and  water,  dry  it,  and  rub  it  thoroughly  with  crude  petro- 


Fig.  282. — Ulcers  of  Leg  due  to  Syphilis. 


leum  or  any  bland  ointment,  wiping  away  the  excess  of  grease ; 
and,  secondly,  will  wear  an  elastic  stocking  or  bandage  every  day 
of  his  life.  If  an  elastic  rubber  stocking  is  chosen,  it  should  ex- 
tend from  the  base  of  the  toes  to  the  knee,  omitting  the  heel.  Such 
a  stocking  costs  from  $2  to  $8,  according  to  the  material  (cotton, 
linen,  or  silk)  and  the  manufacturer.  Under  it  should  be  worn  a 
thin  white  cotton  stocking.  This  protects  the  leg  from  the  rub- 
ber, and  the  rubber  from  the  perspiration.  An  ordinary  stocking 
is  worn  outside  of  the  elastic  one.  With  care  such  a  stocking  will 
last  six  months. 

Another  plan  is  to  bandage  the  leg  with  flannel.     Two  yards 


528  INFLAMMATIONS   OF  THE   LEG   AMD   FOOT 

of  coarse  white  flannel  (every  thread  wool)  are  either  torn  or, 
better,  cut  on  the  bias,  into  strips  2j>  inches  wide.  These  strips 
are  sewed  together,  end  to  end,  so  as  to  make  two  roller  bandages, 
each  about  eight  yards  long.  Before  the  patient  leaves  the  bed  in 
the  morning  one  of  these  bandages  is  to  be  applied  from  the  toe 
to  ilic  km  e,  omitting  the  heel,  and  worn  till  bedtime.  One  of  the 
two  bandages  should  be  washed  every  week.  This  method  is 
cheaper  and  cleaner  than  the  other,  and  gives  in  the  hand  of  a 
person  of  ordinary  dexterity  a  more  even  compression  of  the  leg 
than  the  rubber  stocking,  the  latter  being  at  first  too  tight,  and 
soon  st retching  so  as  to  become  too  loose.  It  is,  however,  a  little 
more  trouble  to  apply  a  bandage  than  a  stocking. 

10.  Operative  Treatment. — Chronic  ulcer  of  the  leg  may  be 
treated  by  skin-grafting,  but  the  results  are  not  always  good,  either 
because  the  base  of  the  ulcer  does  not  attacli  the  graft  to  itself,  or 
because  it  affords  such  poor  nourishment  that  a  part  or  the  whole 
of  the  graft  breaks  down  within  a  few  weeks.  Before  attempting 
skin-grafting  the  circulation  in  the  vicinity  of  the  ulcer  should 
be  improved  by  bathing  the  leg  with  hot  water  and  giving  it  a  good 
rub  once  or  twice  daily.  Even  after  a  thorough  preparation  of 
this  sort,  the  base  of  an  old  ulcer  may  have  very  little  vitality. 
It  may  even  be  infiltrated  with  lime  salts  to  such  an  extent  as  to 
lead  one  to  suppose  that  the  tibia  is  exposed ;  but  the  signs  of  a 
bone  ulcer — viz.,  periosteal  swelling,  sinus  formation,  and  the  loos- 
ening and  casting  off  of  necrotic  bone — will  of  course  be  wanting. 
If  there  is  such  a  calcified  base  to  the  ulcer,  it  should  be  dissected 
out  and  the  skin  applied  to  the  base  of  the  wound,  or  the  skin- 
grafting  postponed  until  new  granulations  have  formed.  The  de- 
tails of  skin-grafting  are  given  on  page  577.  The  leg  of  an  un- 
healthy or  aged  person  is  a  most  unfavorable  site  for  skin-grafting, 
so  one  should  be  guarded  in  prognosis.  Sometimes  the  grafts  will 
not  attach  themselves,  sometimes  they  atrophy  from  lack  of  nutri- 
tion while  the  patient  is  still  in  bed,  and  sometimes  they  ulcerate 
from  the  same  cause  or  from  traumatism  after  the  patient  gets 
up.  Even  after  such  a  graft  has  firmly  attached  itself,  the  pa- 
tient should  spend  a  good  deal  of  time  in  a  horizontal  position 
until  the  new  skin  grows  strong.  It  should  also  be  protected 
against  slight  traumatisms,  such  as  the  rubbing  of  the  clothing 
against  it. 


PERFORATING  ULCER  OF  THE  FOOT 


529 


Ulcer  Exposing  Bone. — The  tibia  may  be  exposed  in  case  of  a 
traumatic  ulcer  (Fig.  283),  but  even  if  the  periosteum  is  carried 
away  by  the  injury,  the  underlying  bone  need  not  necessarily  die. 


Fig.  283. — Traumatic  Ulcer  of  Leg  Exposing  the  Tibia,  One  Week  after  In- 
jury. The  white  spot  in  the  center  of  the  ulcer  is  the  bare  bone,  not  dead  how- 
ever.    Patient  a  man  aged  twenty-two  years. 

It  may  send  out  granulations  from  its  interstices,  which  shall 
form  a  soil  for  the  growth  of  epithelium  until  the  ulcer  is  quite 
healed. 

Perforating  Ulcer. — Callosities  on  the  first  or  second  or 
third  toe,  or  on  the  ball  of  the  foot,  often  give  pain  and  are  pared 
away  with  a  knife  or  scissors.  In  this  manner  infection  may  occur 
and  lead  to  an  abscess.     If  the  pus  strips  up  the  callosity  from  the 


530 


INFLAMMATIONS   OF  THE   LEG   AND   FOOT 


deepesl  layer  of  epithelium,  and  then  either  breaks  through  the 
superficial  skin  or  is  evacuated,  it  may  cure  the  patient  of  his 
callosity.  Instead  of  this  happy  result,  one  usually  finds  that 
the  callus  has  heen  only  partly  separated  from  the  deeper  skin, 
and  that  beneath  it  is  a  small  deep  ulcer;  hence  the  name  per- 
forating ulcer  (Fig. 
284).  Sucjh  an  ul- 
cer, bounded  as  i1 
is  by  lough,  thick, 
slowly  growing  skin 
and  occurring  usu- 
ally in  those  past 
middle  age,  is  ex- 
tremely difficult  to 
heal.  The  surround- 
ing edge  of  the  skin 
should  be  pared 
away,  or  removed 
with  a  salve  con- 
taining ten  per  cent 
of  salicylic  acid. 
Every  effort  should 
be  made  to  keep  the 
parts  soft  and  pli- 
able at  the  same 
time  that  the  treat- 
ment of  the  ulcer 
itself  is  carried  out 
in  accordance  with 
the  principles  given 
in  the  preceding 
pages.  Plastic  operations  aiming  to  cure  the  ulcer  by  skin-grafts, 
or  by  flaps,  are  usually  unsuccessful.  If  neglected,  the  per- 
foration may  extend  and  cause  the  loss  of  one  or  more  toes  (Figs. 
285  and  286).  The  urine  of  these  patients  should  always  be 
carefully  examined,  as  many  of  them  have  either  nephritis  or 
diabetes. 


1 

Jm                ^H 

w 

;•'"■■. 

A  ^ 

wf 

Fig.  284. — Perforating  Ulcers  of  Foot,  Duration 
Six  Months.  Patient  a  man  aged  thirty -eight 
years. 


Pig.  285. — Perforating  Ulcers  of  Toes,  Two  Years.     Patient  a  man  aged  fifty 

years. 


Fig.  286. — Dorsal,  View  of  Same  Foot  as  Shown  in  Fig.  285,  and  also  of  the 
Right  Foot,  One  of  the  Toes  of  which  was  Lost  as  a  Result  of  Similar 
Ulceration. 

36  531 


532  INFLAMMATIONS   OF   THE   LEG   AND    FOOT 

ARTHRITIC  AND  CHRONIC  INFLAMMATIONS 

Suppurative  Synovitis.— Suppuration  in  the  knee-joint  or 
other  joint  of  the  lower  extremity  may  follow  a  compound  fracture 
or  a  punctured  or  incised  wound,  or  a  carelessly  performed  aspira- 
tion for  serous  synovitis.  It  may  also  develop  from  the  hlood  in 
acute  infectious  diseases,  or  in  gonorrheal  arthritis.  In  the  last 
named  disease  the  fluid  in  the  joint  may  be  seropurulent  or  puru- 
lent, from  a  mixture  of  gonocoeci  and  pyogenic  organisms;  finally, 
suppuration  in  the  bone  (osteomyelitis),  or  in  the  soft  parts  (boil 
or  abscess),  may  break  into  the  joint. 

The  signs  of  suppurative  synovitis  are  the  same  as  those  of 
serous  synovitis  (p.  483),  plus  increased  pain  and  tenderness,  and 
edema  and  redness  of  the  periarthritic  soft  tissues,  so  that  fluctua- 
tion in  the  joint  may  be  masked  by  these  added  signs. 

Treatment. — The  course  of  the  disease  in  mild  cases  may  be 
toward  spontaneous  recovery;  but  unless  both  general  and  local 
symptoms  steadily  improve,  the  surgeon  should  not  rest  content 
with  the  milder  forms  of  treatment  suited  to  serous  synovitis,  but 
should  aspirate  to  prove  the  presence  of  pus,  and  then  drain.  Such 
a  joint  soon  suffers  permanent  injury.  The  cartilages  erode,  and 
the  bones  may  necrose  before  nature  gives  relief  by  the  establish- 
ment of  fistulse  to  the  surface. 

In  case  of  wounds  which  may  involve  the  joint,  an  incision 
should  be  at  once  made,  at  least  to  the  capsule.  If  the  capsule  is 
not  visibly  injured,  or  if  there  is  a  probability  from  the  character 
of  the  injury  that  the  joint  cavity  is  not  infected,  drains  should  be 
placed  so  as  to  reach  the  capsule,  but  not  enter  it.  If  the  joint 
has  been  visibly  opened,  or  if  there  is  probability  of  its  infection, 
it  should  be  freely  incised  and  irrigated  with  saline,  and  drained 
with  rubber  tissue.  A  wet  dressing  should  be  applied  and  the  limb 
elevated,  and  kept  at  rest  by  a  splint.  (See  also  p.  425  for  the  later 
treatment  of  an  inflamed  joint  in  order  to  increase  its  mobility. 

Some  of  the  special  forms  of  inflammation  involving  the  lesser 
joints  of  the  lower  extremity,  or  the  larger  joints  to  a  lesser  de- 
gree, require  further  mention. 

The  joints  of  the  foot  in  diabetic,  nephritic,  and  otherwise 
debilitated  individuals  often  become  the  seat  of  a  chronic  sup- 
puration developing  from  trivial  causes.      Thus  the  first  meta- 


GONORRHEAL   ARTHRITIS  533 

tarsophalangeal  joint  (less  often  the  others)  may  suppurate  as 
a  result  of  infection  of  a  corn  or  callus  on  the  sole  or  side  of  the 
foot.  While  this  lesion  is  analogous  to  suppurative  arthritis  of 
the  hand  (p.  423),  it  is  far  more  difficult  to  get  rid  of,  even  with 
the  patient  in  bed,  both  because  of  the  poorer  circulation  of  blood 
in  the  foot  and  because  it  generally  occurs  in  persons  of  middle 
age  or  older,  who  are  not  entirely  healthy.  Diabetes,  gout,  endar- 
teritis, and  chronic  nephritis  should  always  be  borne  in  mind  and 
differential  diagnostic  tests  made.  If  any  one  of  these  diseases  is 
found  to  exist,  and  acute  symptoms  do  not  promptly  subside  when 
a  lateral  incision  has  been  made  into  the  joint,  resection  of  the 
joint  or  amputation  of  the  toe  above  the  joint  or  of  the  foot  is 
advisable ;  for  even  if  incision  and  drainage  give  temporary  relief, 
a  sinus  will  probably  persist,  with  a  slow  necrosis  of  the  end  of 
the  bones  making  up  the  joint. 

Rheumatism. — In  acute  rheumatism  the  inflammation  rarely 
goes  on  to  suppuration,  but  recovery  is  favored  and  pain  relieved 
by  rest  to  the  affected  joints  secured  by  a  splint  or  rest  in  bed. 
Guaiacol,  twenty  drops  on  cotton  covered  with  rubber  tissue,  is  a 
good  local  application.  The  salicylates  should  be  given  internally, 
ten  grains  more  or  less  every  four  hours.  It  is  well  worth  remem- 
bering that  in  some  cases  acute  rheumatism  is  confined  to  a  single 
joint.  This  proportion  is  given  by  some  writers  as  high  as  twenty 
per  cent. 

Gonorrheal  Arthritis.- — The  knee  is  frequently  a  seat  of 
gonorrheal  inflammation,  being  attacked  about  as  often  as  the  wrist. 
While  gonorrheal  arthritis  is  usually  monarticular,  it  occurs  in 
more  than  one  joint  in  perhaps  twenty-five  per  cent  of  the  cases  in 
which  the  joints  become  involved  at  all.  The  affection  develops 
rather  slowly,  but  gives  in  the  course  of  a  few  days  in  a  striking 
manner  the  cardinal  symptoms  of  pain,  heat,  redness,  swelling, 
and  loss  of  function.  A  history  of  gonorrhea  within  a  few  weeks 
past  can  usually  be  obtained,  and  a  drop  or  two  of  pus  can  usually 
be  expressed  from  the  meatus  of  the  male  patient.  If  the  diagnosis 
is  still  doubtful,  fluid  may  be  withdrawn  from  the  joint,  for  micro- 
scopic examination.  This  should  be  done  with  the  strictest  aseptic 
precautions.  Tuberculosis  is  common  in  the  knee,  but  develops 
more  slowly.  Gout  and  syphilis  are  more  prone  to  attack  the 
smaller  joints  of  the  foot,  and  each  has  its  own  history. 


534  I  \l  I. ANIMATIONS    OK    THE    TEC!    AND    FOOT 

Treatment. — We1  dressings  and  a  posterior  splint,  and  as 
much  rest  to  the  limb  in  a  Longitudinal  position  as  the  patient 
can  afford,  should  be  the  principles  of  treatment.  Baking  is  ex- 
cellent to  relieve  pain  and  reduce  swelling.  Later,  counter-irritants 
and  strapping  (p.  493)  are  good  measures  with  massage,  when 
the  acute,  inflammation  has  entirely  subsided.  It  may  be  several 
months  before  all  of  the  symptoms  due  to  gonorrheal  inflammation 
of  the  knee  disappear,  but  the  functions  of  the  joint  are  seldom 
permanently  impaired.  The  effusion  into  the  joint  may  be  so 
great  that  aspiration,  or  even  incision  and  drainage,  are  advisable 
to  preserve  the  vitality  of  the  tissues. 

Gout. — This  disease  produces  such  veil  known  gastric,  ne- 
phritic, cutaneous  and  nervous  symptoms  that  its  local  lesions  are 
not  often  mistaken  for  anything  else.  The  treatment  is  usually 
not  surgical,  but  if  the  urates  accumulate  in  a  position  to  incom- 
mode the  patient,  they  should  be  removed.  Such  is  not  infre- 
'quently  the  case  with  deposits  in  the  feet,  There  is  a  wide-spread 
hesitation  to  perform  any  surgical  operation  upon  a  gouty  patient, 
but  a  small  dissection  requiring  only  local  anesthesia  produces  no 
noticeable  shock,  and  is  followed  by  just  as  prompt  healing  as  when 
performed  upon  the  non-gouty.  If  the  urates  ulcerate  through  the 
skin,  the  opening  should  be  enlarged,  and  the  foreign  matter  re- 
moved. If  a  joint  suppurates,  it  should  be  drained,  or  if  necessary 
resected. 

It  is  only  in  the  exceptional  case  that  operative  treatment  is 
required.  For  the  most  part  the  local  treatment  consists  in  hot 
applications  and  rest  to  the  affected  joint,  while  the  general  treat- 
ment includes  the  use  of  colchicin,  diuretics,  laxatives,  and  ano- 
dynes, according  to  circumstances. 

Syphilis. — The  various  lesions  of  syphilis  later  than  the  pri- 
mary lesion  are  regularly  found  in  the  lower  extremity.  Of  the 
deeper  lesions,  gumma  of  the  skin  and  subcutaneous  fat  may  pro- 
duce a  sluggish  ulceration,  with  indurated  margin  and  possibly 
overhanging  edges ;  while  at  a  later  stage  of  the  lesion,  when  the 
induration  has  disappeared  and  the  cavity  has  partially  filled  with 
granulations,  the  appearance  differs  little  from  that  of  any  healing 
ulcer. 

Syphilitic  periostitis  of  the  tibia  is  common.  It  does  not  usu- 
ally lead  to  ulceration,  but  forms  a  diffuse  swelling  which  lasts 


TUBERCULOSIS  535 

a  long  time,  and  is  especially  painful  at  night,  and  may  leave 
some  permanent  thickening  of  the  bone.  The  usual  form  of 
gumma  with  ulceration  may  also  occur. 

Another  late  manifestation  of  syphilis  in  the  lower  extremity 
is  the  involvement  of  a  joint  or  joints.  Either  the  periarticular 
tissues  may  be  the  seat  of  the  gummata  or  the  bones  themselves. 
According  to  the  degree  of  severity  there  may  be  fluid  in  the 
joint,  or  general  swelling  with  plastic  adhesions,  or  erosion  of 
cartilages,  ankylosis,  and  contraction  of  the  muscles. 

Tkeatment. — The  usual  antisyphilitic  treatment  should  be 
employed  (p.  61).  In  addition  there  should  be  rest  to  the  affected 
parts,  during  the  acute  stage,  and  massage  and  passive  and  active 
motions  to  restore  the  use  of  the  joints  after  the  acute  symptoms 
have  passed  over.  For  this  purpose  a  rocking-chair  and  teeter 
are  very  serviceable.  Treatment  suitable  for  the  ulcers  is  de- 
scribed on  page  521. 

Tuberculosis.- — In  making  an  early  diagnosis  of  joint  tuber- 
culosis, one  should  not  be  misled  by  the  history  of  a  fall  or  a 
slight  sprain.  This  injury  may  be  the  beginning  of  the  tuberculous 
lesion,  or  it  may  simply  have  served  to  call  the  attention  of  the 
patient  to  a  joint  already  involved  by  tuberculosis.  The  existence 
of  swelling  in  the  joint,  of  slight  atrophy  of  the  muscles  above  and 
below  the  joint,  of  tenderness  of  one  of  the  bones  of  the  joint,  and 
of  muscular  spasm  when  the  joint  is  moved  to  the  limit  in  various 
directions,  ought  to  convince  the  examiner  that  he  is  dealing  with 
something  more  serious  than  a  sprain.  If  he  is  still  in  doubt  he 
should  keep  the  part  at  rest  and  examine  it  again  in  a  few  days. 
If  there  is  only  a  sprain,  the  symptoms  will  have  disappeared  for 
the  most  part.  If  there  is  tuberculosis,  the  symptoms  will  be  essen- 
tially the  same,  though  the  tenderness  and  swelling  usually  subside 
somewhat  under  the  influence  of  rest.  There  will  also  be  a  slight 
afternoon  fever.  The  X-ray  may  show  the  affected  bone  to  be 
less  dense  in  places,  and  perhaps  a  little  larger  than  normal. 

Teeatment. — If  the  patient  is  a  child,  whether  the  tubercu- 
losis is  in  the  hip,  knee,  or  ankle,  a  suitable  brace  should  be  pro- 
vided to  keep  the  inflamed  joint  quiet,  and  to  take  from  it  the 
weight  of  the  body.  If  the  patient  is  an  adult  the  case  is  somewhat 
different.  He  will  usually  prefer  crutches  to  a  brace,  and  because 
his  chance  of  successfully  overcoming  the  disease  is  not  as  great 


530  INFLAMMATIONS    OF   THE    LEO    AND    FOOT 

as  it  is  in  childhood,  the  question  of  operative  removal  of  the 
affected  tissues  by  resection  or  amputation  ought  to  receive  early 
consideration. 

The  treatment  which  has  proved  so  beneficial  to  many  patients 
having  pulmonary  tuberculosis  is  equally  desirable  for  those  suf- 
fering from  tuberculosis  of  the  bones  and  joints.  The  essentials 
of  this  treatment  are  a  constant  supply  of  fresh  air,  a  large  supply 
of  food,  especially  of  fats,  and  a  rapid  carrying  off  of  the  waste 
products  by  the  free  use  of  cathartics.  One  or  two  spoonfuls  of  the 
juice  which  can  be  squeezed  from  freshly  ground  raw  vegetables 
may  be  given  to  the  patient  immediately  after  his  noonday  and 
evening  meals,  to  increase  his  appetite  and  his  ability  to  utilize 
large  quantities  of  food.  This  treatment,  recommended  by  Russell 
for  patients  with  pulmonary  tuberculosis,  is  equally  adapted  to 
patients  who  have  tuberculosis  of  the  bones  and  joints. 

Treatment  should  be  continued  for  a  long  time,  as  it  takes  from 
one  to  three  years  for  even  a  child  to  recover  fully  from  a  tuber- 
culous lesion. 


CHAPTER    XIX 
TUMORS  AND  DEFORMITIES  OF  THE  LEG  AND    FOOT 

TUMORS 

Callus. — A  callus  is  a  thickening  of  the  epidermis  due  to  its 
repeated  pressure  between  a  bone  and  some  hard  surface  outside  of 
the  body.  When  this  repeated  pressure  first  occurs,  blisters  may 
be  formed.  If  the  traumatism  is  often  repeated,  the  epithelium 
thickens,  and  a  callus  results. 

In  many  instances  a  callus  is  a  protection  to  the  body,  and 
need  not  be  disturbed.  In  some  cases,  however,  it  becomes  so  hard 
that  the  underlying  sensitive  skin  is  painfully  pressed  upon.  This 
is  especially  true  of  calluses  upon  the  sole  of  the  foot.  Under 
such  circumstances  the  outer  portion  of  the  callus  should  be  re- 
moved. 

Before  cutting  away  the  outer  portion  of  a  callus  the  skin 
should  be  thoroughly  softened  by  soaking  it  in  a  hot  alkaline  solu- 
tion. Washing  soda  answers  well  for  this  purpose.  The  outer 
portion  of  the  callus  should  then  be  scraped  or  pared  away.  The 
process  should  be  repeated  on  succeeding  days  until  the  skin  be- 
comes sufficiently  flexible.  Great  care  should  be  taken  not  to  cut 
into  the  living  skin,  as  infection  started  in  this  manner  often 
burrows  beneath  the  callus,  and  is  extremely  difficult  to  stop  (p. 
529).  Another  method  of  removing  a  surplus  callus  is  to  apply 
to  it  an  ointment  containing  salicylic  acid,  a  dram  to  the  ounce; 
or  it  may  be  painted  with  salicylic  acid  collodion.  Two  or  three 
days  later  the  first  layer  of  thickened  skin  will  have  softened  so 
that  it  can  be  removed  from  a  considerable  area.  The  acid  should 
then  be  reapplied,  but  care  should  be  taken  to  confine  the  subse- 
quent applications  to  the  portion  of  skin  which  is  still  abnormally 
thick.  Flatfoot  or  other  deformity  which  causes  the  excessive 
pressure  should  be  corrected,  and  suitable  shoes  should  be  pro- 
vided. 

537 


538       TUMORS   AND   DEFORMITIES   OF   THE   LEG   AND   FOOT 

Corn. — A  corn  is  a  circumscribed  thickening  of  the  epider- 
mis, usually  occurring  at  a  point  where  the  skin  is  pressed  between 
a  bony  prominence  and  the  shoe.  In  these  respects  it  resembles  a 
callus.  Jt  differs  from  it  in  possessing  a  central  peg,  or  core. 
Another  point  of  difference  is  the  possibility  that  a  corn  may 
develop  between  the  toes.  Such  a  corn  is  often  kept  in  a 
macerated  ^condition  by  the  moisture,  and  is  therefore  called  a 
soft  corn. 

The  treatment  of  a  corn  is  similar  to  that  of  a  callus.  After 
the  outer  portion  has  been  softened  and  removed,  the  central  peg 
should  be  dissected  out.  In  some  corns  there  are  more  than  one 
of  these  conical  thickenings.  Salicylic  acid  is  the  active  principle 
of  most  of  the  advertised  corn  cures.  The  treatment  of  a  soft  corn 
is  similar,  but,  owing  to  the  more  delicate  nature  of  the  skin, 
applications  should  be  milder,  or  should  be  left  in  place  for  a 
shorter  period.  Shoes  should  be  changed  so  that  pressure  upon 
the  affected  spot  may  be  avoided ;  but  even  when  this  is  accom- 
plished, it  takes  a  long  time  to  overcome  the  tendency  of  the 
epithelium  to  conical  thickening. 

Varicose  Veins. — Varicose  veins  come  chiefly  to  notice  as 
one  of  the  predisposing  causes  of  ulcer  of  the  leg.  They  may  even 
without  ulceration  give  the  patient  so  much  trouble  that  he  seeks 
surgical  relief.  They  are  most  commonly  found  in  women  who 
have  borne  many  children,  and  who  during  their  pregnancies  have 
been  obliged  to  be  on  their  feet  all  day  long,  in  spite  of  warning 
pains  in  the  thighs  and  legs ;  but  any  person  who  is  on  his  feet  a 
great  deal  may  have  varicose  veins. 

The  veins  that  become  distended  may  be  few  or  many.  They 
may  also  be  large  or  small.  The  internal  saphenous  vein  and 
some  of  its  branches  are  most  often  affected.  The  trouble  may 
extend  from  the  toes  to  the  groin,  or  it  may  be  limited  to  some 
portion  of  the  extremity.  The  skin  often  becomes  erythematous 
and  pigmented  in  places,  and  may  easily  break  down  and  ulcerate. 

The  chief  symptom  of  varicose  veins  is  an  aching  pain  and 
heaviness  in  the  affected  leg.  Edema,  especially  toward  night,  is 
not.  uncommon.  If  the  veins  become  inflamed,  as  they  often  do,  the 
pain  becomes  acute,  and  there  is  a  localized  tender,  red,  edematous 
swelling,  in  the  center  of  which  the  inflamed  vein  can  often  be 
felt  as  a  thickened,  hard  cord.     (See  Phlebitis,  p.  515.) 


VARICOSE   VEINS  530 

Treatment. — The  best  palliative  treatment  for  varicose  veins 
is  an  elastic  bandage,  to  be  applied  in  the  morning  before  the 
patient  leaves  his  bed,  and  to  be  taken  off  at  night  (p.  527).  If 
this  is  too  much  trouble,  an  elastic  stocking  may  be  worn.  Natu- 
rally, such  treatment  will  not  cure  the  dilatation,  but  it  will  pre- 
vent it  from  increasing,  and  will  relieve  the  patient  of  the  pain 
which  often  accompanies  enlarged  veins,  and  will  avert  the  more 
serious  sequela? — rupture,  ulcer,  and  phlebitis. 

If  more  radical  treatment  is  called  for,  the  affected  vein  may 
be  ligated  in  a  number  of  places.  This  operation  is  easily  car- 
ried out  under  a  local  anesthetic,  each  incision  half  an  inch  to 
an  inch  in  length,  being  made  directly  down  upon  an  enlarged 
venous  trunk,  parallel  to  its  lumen.  The  vein  being  exposed  is 
separated  from  its  bed,  ligated  in  two  places,  and  divided  between 
the  ligatures.  If  the  blood  current  is  interrupted  in  half  a  dozen 
places  in  this  manner,  and  especially  if  the  saphenous  vein  is 
ligated  just  below  its  termination  at  the  saphenous  opening  at  the 
upper  end  of  the  thigh,  the  effect  upon  the  general  dilatation  will 
be  considerable.  Each  wound  in  the  skin  should  be  closed  with 
silk  sutures. 

A  more  radical  operation  is  the  removal  of  an  entire  dilated 
vein,  or  of  its  most  prominent  portions.  When  the  vein  is  ex- 
posed by  a  skin  incision,  it  can  be  dissected  out  of  its  bed  partly 
by  blunt  instruments  and  partly  by  scissors.  This  operation  may 
be  carried  out  by  using  a  local  anesthetic,  or  a  general  anes- 
thetic may  be  preferred.  A  light  ligature  above  the  operative 
field  keeps  the  veins  full,  and  the  dissection  should  be  made  from 
below  upward.  The  surgeon  should  be  on  his  guard  against  trou- 
blesome bleeding  which  can  easily  follow  the  division  of  a  deep 
branch,  whose  mouth  is  sometimes  found  with  difficulty.  On 
account  of  this  risk  of  loss  of  blood,  as  well  as  because  of  the  more 
extensive  incisions,  this  operation  should  be  followed  by  a  rest 
in  bed  of  a  few  days,  which  the  simple  ligation  and  division  of  the 
veins  does  not  require.  After  either  operation  a  dry  dressing 
should  be  applied  and  kept  in  place  until  the  stitches  are  removed 
on  the  fifth  day. 

The  choice  of  treatment  for  dilated  veins  of  the  leg  will  de- 
pend not  only  on  the  size  and  situation  of  the  veins,  but  still  more 
on  their  number.     If  veins  on  all  sides  of  the  limb  are  much  en- 


540      TUMORS  AND  DEFORMITIES  OF  THE   LEG   AND   FOOT 

larged,  it  is  a  hopeless  task  to  attempt  their  cure  by  removal, 
especially  as  the  deeper  branches  will  in  such  instances  be  found 
to  be  dilated  also.  If,  on  the  other  hand,  a  single  large  trunk  with 
a  few  branches  is  involved;,  a  permanent  euro  may  be  effected, 
even  if  the  dissection  has  to  extend  from  the  ankle  nearly  to  the 
saphenous  opening. 

In  this  last  class  of  cases  the  subcutaneous  method  of  dissec- 
tion recommended  by  Mayo  is  of  service,  lie  exposes  the  vein 
high  up,  divides  it.  and  passes  over  the  lower  portion  an  instru- 
ment which  resembles  a  dull  wire  curette.  This  can  be  wormed 
along-  beneath  the  skin,  dissecting  out  the  vein  until  it  breaks, 
usually  three  or  four  inches  from  the  first  exposure.  The  beak 
of  the  instrument  is  then  pushed  against  the  skin  and  cut  down 
upon.  The  lower  end  of  the  vein  is  seized,  the  instrument  is 
withdrawn  and  passed  over  the  vein. in  the  new  opening,  another 
worming  downward  takes  place  until  the  vein  again  breaks,  etc. 
Side  branches  as  they  are  torn  off  may  be  followed  or  simply  li- 
gated  according  to  their  size. 

Aneurism. — The  popliteal  artery  is  the  one  artery  of  the 
lower  extremity  especially  liable  to  undergo  dilatation.  The  diag- 
nosis is  easy  even  in  an  early  stage  if  one  tests  for  expansile  pulsa- 
tion. The  only  other  cystic  swelling  in  this  vicinity  is  distention 
of  the  bursa  under  the  inner  head  of  the  gastrocnemius  and  tendon 
of  the  semimembranosus  muscles.  The  distended  bursa  is  not  situ- 
ated in  the  same  place  as  the  popliteal  artery  and  it  does  not 
pulsate  (p.  481). 

The  cure  of  aneurism  by  pressure  and  by  operation  is  fully 
discussed  in  text-books  on  major  surgery.  Since  the  improvement 
of  operation  for  this  lesion,  other  methods  of  cure  are  seldom  em- 
ployed; and  yet  it  is  worth  remembering  that  many  cases  of 
popliteal  aneurism  have  been  cured  by  digital  pressure  continued 
by  frequent  changes  of  assistants  one  or  two  days,  until  the  blood 
in  the  sac  coagulates. 

Ganglion.  —This  may  occur  in  the  foot  as  well  as  in  the 
hand  (but  it  is  rare).  It  may  be  treated  by  aspiration  and  injec- 
tion or  by  excision.      (For  diagnosis  and  treatment  see  p.  445.) 

Sebaceous  Cyst. — This  tumor,  so  common  in  the  upper  por- 
tion of  the  body,  is  seldom  found  below  the  hips.  (For  diagnosis 
and  treatment  see  p.  67.) 


OSTEOMA 


541 


Lipoma  and  Fi- 
brolipoma.  —  These 
tumors  are  occasional- 
ly found  on  the  thighs. 
(For  their  diagnosis 
and  treatment  see  p. 
185.) 

Fibroma. — A  tu- 
mor of  the  appearance 
of  a  pure  fibroma 
should  always  be  looked 
on  with  suspicion,  and 
subjected  to  a  careful 
microscopic  examina- 
tion. It  will  often  turn 
out  to  be  a  sarcoma, 
either  spindle-celled  or 
made  up  of  small 
round  cells. 

Osteoma.  —  Any 
bone  may  be  the  seat 
of  an  osteoma.     In  the 


Fig.  288. — Osteoma  of  the  Great 
Toe  Growing  under  the  Nail 
and  Pushing  the  Nail  Before 
It.  Duration  five  months ;  patient 
a  woman  aged  thirty-four  years. 


Fig.  287. — Osteoma  of  the  Tibia  of  Three 
Years'  Duration  in  a  Boy  aged  Four- 
teen Years. 


lower  extremity  these  tumors  are 
chiefly  found  growing  from  the 
femur  or  tibia  (Fig.  287)  or 
from  the  dorsal  surface  of  the 
last  phalanx  of  the  great  toe  (Fig. 
288)..  The  nail  is  lifted  from  its 
bed  by  the  tumor,  which  grows 
almost  directly  upward. 

TitEATMENT.^If  an  osteoma 
is  troublesome,  it  should  be  re- 
moved together  Avith  its  attach- 
ment to  the  bone.  A  pathological 
examination  should  always  be 
made  to  rule  out  the  possibility  of 


."ill'       TIMulis    AM)    DKI'dUMITIKS    OF    T1IK    LEG    AND    FOOT 

osteosarcoma.  The  osteoma  of  the  tibia  shown  in  the  illustra- 
tion gave  no  trouble.  Snch  a  tumor  should  be  radiographed 
and  then  merely  be  kept  under  observation  to  rule  out  the  pos- 
sibility of  malignancy.  The  osteoma  under  the  nail  prevented 
the  comfortable  use  of  an  ordinary  shoe,  and  was  therefore 
removed. 

Sarcoina. — All  kinds  of  sarcomata  are  found  in  the  lover  ex- 
tremity, and  they  may  arise  in  any  tissue  plane  from  the  skin 
to  the  marrow  of  the  bones.  The  forms  that  are  especially  likely 
to  lead  to  a  mistake  in  diagnosis  are  sarcoma  of  the  knee  or  of 
the  femur  near  the  knee,  simulating  tuberculosis;  sarcoma  of  the 
shaft  of  a  bone,  especially  of  the  tibia,  simulating  syphilis ;  sar- 
coma of  the  skin  or  subcutaneous  tissue,  simulating  fibroma,  and 


Fig.  2S9. — Sarcoma  of  Great  Toe  from  Injury  Nine  Months  Previous.     Patient 
a  man  aged  fifty-one  years. 


sarcoma  of  the  toes,  simulating  senile  or  diabetic  gangrene.  An 
instance  of  the  last  named  type  is  shown  in  Figure  289.  It  de- 
veloped soon  after  a  traumatism,  as  sarcoma  often  does. 

Treatment. — As  soon  as  the  diagnosis  is  made  the  tumor 
should  be  removed,  and  with  it  enough  of  the  healthy  tissue  to 
make  recurrence  unlikely.  This  usually  means  an  amputation. 
The  only   sarcomata  therefore  whose  treatment  lies  within  the 


CARCINOMA 


543 


field  of  minor  surgery  are  those  which  arise  in  the  skin  or  close 
to  it.  The  removal  of  such  tumors  has  been  described  on  page 
462.  The  deeper  sarcomata  of  the  lower  extremity  afford  some 
of  the  hardest  problems  which  the  surgeon  has  to  solve. 

Carcinoma. — A  carcinoma  of  the  lower  extremity  almost 
always  starts  in  an  ulcer.  Although  this  is  not  a  common  out- 
come of  an  ulcer  of  the  leg, 
it  is  worth  bearing  in  mind. 
Fortunately  such  a  tumor  in 
its  early  months  does  not  ex- 
tend far  below  the  surface  nor 
form  metastases,  and  it  can 
therefore  be  easily  removed, 
and  will  not  be  likely  to 
recur. 

The  hard  growing  edges 
and  sloughy  base  of  such  an 
ulcer  give  it  a  characteristic 
appearance  in  many  cases 
(Fig.  290).  In  other  cases 
the  appearance  is  less  charac- 
teristic, and  it  may  be  neces- 
sary to  remove  a  section  for 
microscopic  examination  be- 
fore an  absolute  diagnosis  can 
be  made. 

Treatment. — If  an  ulcer  or  any  portion  of  it  is  found  to  be 
carcinomatous  in  character,  it  should  be  at  once  removed,  the  cut 
being  well  away  from  suspicious  tissue.  In  most  cases  it  will 
be  found  advisable  to  cover  the  wound  with  skin-grafts,  either 
at  the  time  or  after  granulations  have  formed  (p.  577).  Such  an 
operation,  unless  the  area  is  very  small,  can  best  be  carried  out 
with  a  general  anesthetic,  and  requires  a  few  days'  rest  in  bed. 


Fig.  290. — Carcinoma  Developing  in 
an  Old  Ulcer  of  the  Leg  of  a  Fe- 
male Patient. 


ACQUIRED   DEFORMITIES 

There  are  several  deformities  acquired  from  ill-shaped  shoes 
which  are  amenable  to  ambulant  treatment.  These  deformities 
may  be  of  the  nails  (twisted  nail,  ingrown  nail),  or  of  the  toes 


544       TUMORS    AND    DEFORMITIES    OF   THE   LEG    AND    FOOT 


(hallux  valgus,  haminer-toe),  or  of  the  foot  (flatfoot,  weak  foot). 
In  all  these  deformities  proper  s1k.cs  should  be  insisted  on.  Bui 
a  change  from  bad  to  good  shoes  will  not  repair  the  mischief  done 
excepl  to  a  slight  degree  and  often  enough  the  patient  has  made 
such  a  change  long  before  consulting  the  surgeon. 

Twisted  Nails.  Twisted  nails  are  found  usually  in  old  per- 
sons, both  men  and  women,  and  are  due  to  long  continued  pressure 
of  pointed  or  short  shoes.  By  such  pressure  on  the  nails  the  ma- 
trices have  been  twisted,  and  the  nails  grow  out  in  a  curve  toward 
the  outer  margin  of  the  foot.     This  tendency  can  be  observed  in 

many  persons,  but  it  is  espe- 
cially prominent  in  the  aged, 
whose  nails  often  become  so 
thick  that  they  are  cut  with 
difficulty  (Fig.  291).  Such 
nails  are  sometimes  allowed 
to  grow  very  long  before  med- 
ical assistance  is  sought  for. 
They  can  be  clipped  short 
with  wire  nippers  or  bone 
shears,  without  an  anesthetic, 
or  cocain  may  be  inserted 
around  the  base  of  the  nail, 
the  skin  loosened  and  pushed 
back,  and  the  nail  twisted 
over  and  removed.  In  the 
latter  case  a  dressing  will  be 
required  for  a  few  days  to 
protect  the  toe  until  the  slight 
tenderness  has  disappeared. 
The  new  nail  as  it  grows  out  will  be  like  the  old,  but  the  patient 
will  have  relief  for  a  year  or  more. 

Ingrown  Nail. — This  is  a  condition  in  which  the  edge  of 
the  nail,  usually  of  the  great  toe,  by  its  too  close  contact  with  the 
flesh  beneath  causes  irritation,  ulceration,  or  suppuration.  There 
has  been  much  discussion  as  to  whether  the  nail  or  the  flesh  is 
the  more  at  fault.  This  discussion  is  without  profit.  It  is  much 
better  to  study  the  normal  conditions,  and  see  what  can  be  done 
to  restore  them.     Figure  292,  A  and  By  shows  the  normal  toe- 


Fir,.  291. — Twisted  Nails  of  Three 
Years'  Duration.  Patient  a  woman 
aged  thirty-three  years. 


INGROWN   NAIL  545 

nail  in  longitudinal  and  transverse  section.  The  drawings  are 
from  the  toe  of  a  young  male  adult.  It  is  important  to  note  the 
relations  of  the  matrix  of  the  nail  to  the  first  phalanx  and  to  the 


Fig.  292. — Sections  of  the  Great  Toe  to  Illustrate  the  Pathology  of  In- 
grown Nail  on  which  Successful  Operation  is  Based.  The  nail  is  shown 
dark,  the  matrix  light.  Note  that  the  matrix  extends  almost  to  the  joint. 
A,  longitudinal  section;  B,  transverse  section  at  point  in  A  marked  by  the  arrow. 
The  dotted  lines  mark  out  the  portion  of  the  nail  and  matrix  which  should  be 
removed. 

joint;  since  the  bone  and  joint  are  landmarks  in  the  performance 
of  the  operation  for  the  cure  of  ingrown  nail. 

If  the  nail  is  allowed  to  grow  out  to  the  end  of  a  normal  toe, 
the  ordinary  pressure  of  the  shoe  brings  the  edge  of  the  nail 
against  the  underlying  skin  at  the  end  of  the  toe  where  the  skin 
is  tough,  so  that  no  damage  results.  If  an  ill-fitting  shoe  con- 
stantly rubs  the  toe,  or  if  some  one  steps  on  it,  the  trauma  may 
break  the  underlying  skin.  The  edge  of  the  nail  will  then  be 
in  constant  contact  with  the  sore,  and  will  act  like  a  foreign 
body,  and  prevent  the  ulcer  from  healing. 

This  is  especially  true  if  the  corners  of  the  nail  have  been  cut 
away,  so  that  the  pressure  of  the  nail's  edge  comes  on  the  more 
delicate  skin  by  the  side  of  the  nail,  rather  than  on  the  tougher 
skin  at  the  end  of  the  toe.  The  resulting  inflammation,  ulcera- 
tion, and  granulation  may  go  on  until  the  toe  presents  the  appear- 
ance shown  in  Figure  293. 

Such  a  toe  is  very  painful,  and  the  pain  is  only  partly  relieved 
by  cutting  away  the  upper  of  the  shoe,  etc.  As  there  is  an  easy 
exit  for  the  discharge,  infection  rarely  extends  upward  into  the 


546      TUMORS    \\l»   DEFORMITIES   OF  THE   LEG    AND  FOOT 

Pool  and  leg.    On  the  oilier  hand,  the  conditions  for  repair  are  not 

p I.  v,,  thai  ;i  patienl  may  go  hobbling  aboul  for  months  with  a 

small  nicer  under  the  nail's  edge,  marked  by  an  exuberant  growth 
of  granulations  and  a  slight  discharge. 

Treatment.- — There  are  three  ways  to  cure  the  existing  nicer 
of  an  ingrown  nail:  (a)  One  is  to  interpose  some  protecting  ma- 


Fig.  293. — Ingrown  Nails  op  both  Great  Toes,  Duration  One  Year.     Patient 
a  boy  aged  fifteen  years. 

terial  between  the  edge  of  the  nail  and  the  ulcer;  (&)  another  is 
to  remove  the  edge  of  the  nail  from  the  ulcer;  (c)  and  the  third 
is  to  remove  the  flesh  from  the  edge  of  the  nail. 

In  mild  cases  the  ulcer  due  to  an  ingrown  nail  may  he  cured 
by  depressing  the  flesh  along  its  edge  and  pushing  a  small  wisp 
of  absorbent  cotton  under  it.  This  should  be  wet  with  some 
astringent  solution,  for  example,  silver  nitrate,  1 :  50.  The  upper 
of  the  shoe  should  be  cut  from  the  sole  far  enough  to  relieve  the 
great  toe  from  pressure.  The  dressing  should  be  changed  every 
day  or  two.  Cotton  should  be  kept  under  the  edge  of  the  nail 
until  the  corner  of  the  latter  has  grown  out  to  the  end  of  the  toe. 
Otherwise  the  ulcer  is  likely  to  reform. 

The  nail  can  be  pushed  upward  away  from  the  ulcer  by  means 
of  a  little  silver  hook.     A  thin  strip  of  spring  silver  is  so  bent 


INGROWN   NAIL 


547 


that  it  will  hook  under  the  edge  of  the  nail,  and  then  half  encir- 
cle the  toe,  on  its  plantar  surface.  As  the  patient  steps  on  the  toe 
the  buried  edge  of  the  nail  is  lifted  upward.  The  hook  is  kept  in 
place  by  adhesive  plaster  or  a  bandage.  This  method,  like  that 
of  cotton  and  astringents,  finds  its  best  use  in  mild  cases  occur- 
ring in  people  of  some  intelligence. 

The  edge  of  the  nail  may  be  pared  away,  and  so  separated 
from  the  ulcer.  This  is  the  treatment  of  many  patients  as 
well  as  chiropodists.  It  often  gives  temporary  relief  if  the 
ulcer  does  not  extend  too  near 
the  matrix,  but  it  can  cure 
only  mild  cases  of  ingrown 
nail,  for  as  the  nail  grows 
out  its  corner  digs  again 
into  the  flesh.  For  the  same 
reason,  "  tearing  out  by  the 
roots  "  the  whole  or  a  part  of 
the  nail  is  doomed  to  failure. 
The  matrix  cannot  be  torn  out, 
and  will  grow  another  nail  at 
least  as  distorted  as  its  prede- 
cessor. 


Fig.  294. — Operation  for  Ingrown  Nail.     A,  The  line  of  incision;  B,  the  skin  flaps 
reflected ;  C,  the  section  of  nail  and  corresponding  matrix  removed. 

A  satisfactory  radical  operation  must  remove,  with  the  edge 
of  the  nail,  that  portion  of  the  matrix  from  which  it  grows. 
37 


54S       TUMORS    AND    DEFORMITIES    OF   THE    LEG    AND    FOOT 


The  details  of  this  operation  are  as  follows:  Cleanse  the  toe  as 
thoroughly  as  possible  with  soap  and  water  and  an  antiseptic 
solution;  shut  oft'  the  blood-supply  of  the  toe  by  a  bandage  tied 
about  its  narrowest  part.  Inject  a  local  anesthetic  along  the  edge 
of . the  nail  and  beneath  it  as  far  back  as  the  base  of  the  second 
phalanx.  Cut  through  the  nail  and  overlying  skin  in  a  line  paral- 
lel to  the  axis  of  the  toe  (Fig.  294,  A).  This  cut  should  sepa- 
rate from  the  nail  a  strip  about  one-fourth  of  an  inch  wide,  and 
should  extend  clear  through  the  matrix  of  the  nail — a  dense  white 
layer  easily  differentiated  from  the  subcutaneous  fat  (Fig.  292,  A, 
p.  545).  The  overlying  skin  at  this  side  should  be  dissected  free 
from  this  separated  marginal  strip  of  nail  and  from  its  matrix 
(Fig.  294,5). 

This  strip  of  nail  and  matrix  should  be  dissected  out  by  cuts 
made  above  and  below  it,  and  meeting  well  beyond  it  under  the 

skin  at  the  side  of  the  toe. 
The  surgeon  should  remem- 
ber that  the  nail  grows 
from  the  thick  layer  of  epi- 
thelial cells  placed  both 
above  and  below  the  plane 
of  the  nail,  the  former  ex- 
tending nearly  to  the  re- 
flection of  skin,  and  the 
latter  extending  to  the 
white  semilunar  line.  The 
skin  flaps  are  retracted  and 
the  wound  is  inspected  for 
any  possible  bit  of  matrix 
which  may  have  been  left 
(Fig.  294,  C).  It  is  then 
well  wiped  out  with  an 
antiseptic  solution,  such 
as  a  solution  of  bichlorid, 
1 :  2,000,  and  closed  by  the 
pressure  of  a  wet  dressing 
wrapped  around  the  toe; 
ligation  of  blood-vessels  is  rarely  necessary,  especially  if  the  dress- 
ing is  partly  applied  before  the  constricting  bandage  around  the  toe 


Fig.  295. — Operation  for  Ingrown  Nail, 
Showing  the  Toe  a  Few  Days  after 
Operation.  Same  subject  as  shown  in 
Fig.  293. 


INGROWN    NAIL 


549 


is  removed.  Too  great  pressure  must  not  be  applied  to  the  Lateral 
flap,  however,  lest  sloughing  or  infection  follow.  The  shape  of  the 
wound  facilitates  drainage  if  a  wet  dressing  is  put  on  and  fre- 
quently moistened.  The  dressing  should  be  changed  daily  for 
four  days;  then  if  all 
is  well,  a  dry  dressing 
may  be  substituted  and 
changed  again  every 
three  or  four  days.  If 
the  wound  heals  as  it 
should,  it  will  be  quite 
closed  in  ten  days  (Figs. 
295  and  296).  The 
proximal  half  usually 
closes  by  "  first  inten- 
tion." Sutures  may  be 
inserted,  but  are  not 
necessary. 

The  disfigurement 
after  this  operation  is 
slight,  and  the  function- 
al result  is  perfect. 

In  performing  the 
above  described  opera- 
tion, one  should  bear  in 
mind  that  every  bit  of  the  nail  has  its  corresponding  portion 
of  the  matrix  from  which  it  springs  and  that  growth  of  the  nail, 
except  in  cases  of  distortion,  is  parallel  to  the  long  axis  of 
the  toe.  One  should  not,  therefore,  remove  a  broader  portion 
of  the  matrix  than  will  correspond  to  the  buried  portion  of  the 
nail.  When  this  rule  is  followed,  the  visible  portion  of  the  nail 
will  continue  to  be  formed  and  the  normal  appearance  of  the  toe 
will  be  preserved. 

If  a  portion  of  the  matrix  is  left  in  the  operative  field,  it  may 
grow  up  by  the  side  of  the  nail  in  harmless  stubs  of  nail,  or,  if 
larger,  it  may  grow  a  long  spike  of  nail  which  pierces  the  skin  at 
the  side  of  the  toe  and  renders  a  second  operation  necessary,  or 
it  may  be  unable  to  pierce  the  skin  and  will  then  curl  up,  forming 
a  subcutaneous  mass  of  half  hardened  epithelial  debris. 


Fig.  296. — Operation  for  Ingrown  Nail,  Show- 
ing Toe  Ten  Days  after  Operation.  The 
length  and  position  of  the  skin  incision  are 
plainly  shown  by  the  recent  scar. 


550      Tl  MORS   WD    DEFORMITIES   OF  THE   LEG    A.ND   FOOT 


The  operation  above  described  has  been  developed  in  the 
hands  of  the  author  from  several  cruder  ones,  based  on  the  same 

principle,  of  removing  the  matrix  <>f  (he  otVeuding  portion  of  the 
nail.  Some  of  them  -were  less  certain  in  accomplishment,  and 
some  more  painful  in  execution,  and  some  more  mutilating.  Some 
operators,  in  addition  to  the  removal  of  the  matrix  of  the  in- 
volved pari  of  the  nail,  tear  out  the  whole  formed  nail.  This  lias 
no  advantage,  and  renders  the  toe  mure  or  less  sensitive  for  some 
weeks. 

The  third  method  of  separating  the  edge  of  an  ingrown  nail, 
and  the  ulcer  it  causes,  is  by  removal  of  the  ulcer.  This  is  ac- 
complished by  cutting  away  the  skin  and  subcutaneous  tissue  of 
the  side  of  the  toe.     As  there  is  then  nothing  for  the  nail's  edge 

to  press  against,  the 
soreness  quickly  disap- 
pears. The  wound  left 
to  granulate  is  from 
half  an  inch  to  an  inch 
in  diameter;  so  that 
healing  takes  a  month 
to  six  weeks.  The  ul- 
timate result  is  good, 
but  the  shape  of  the 
toe  is  somewhat  altered 
in  appearance.  This 
operation  hears  the 
name  of  Cotting. 

Hallux  Valgus. 
—Hallux  valgus  is  a 
gradually  formed  ab- 
normal abduction  or 
partial  dislocation  out- 
ward of  the  great  toe, 
due  to  wearing  short  or 
pointed  or  high-heeled 
shoes.  It  is  often  com- 
bined with  an  inflam- 
mation of  the  metatarsophalangeal  bursa,  often  called  a  bunion 
(p.  482),  and  with  hypertrophy  of  the  head  of  the  first  metatarsal 


Fig.  297. — Hallux  Valgus,  with  Hypertrophy 
of  the  Head  of  the  First  Metatarsal,  and 
Displacement  of  the  First  Toe  Outward. 
Note  the  overriding  of  the  other  toes.  The  de- 
formity was  of  many  years'  duration;  the  pa- 
tient a  woman  aged  seventy-two  years. 


HALLUX   VALGUS 


551 


(Fig.  297).  As  the  great  toe  is  swung  further  toward  the  outer 
side  it  may  come  to  lie  either  above  or  less  often  below  the  second 
toe.  The  pull  upon  the 
capsule  of  its  joint  and 
the  hypertrophy  of  the 
head  of  the  metatarsal, 
which  takes  place  al- 
most entirely  on  its 
inner  side,  so  alter  the 
plane  of  the  joint  that 
in  extreme  cases  it 
comes  to  be  as  oblique 
as  the  line  drawn  from 
the  base  of  the  first 
phalanx  to  the  base  of 
the  fifth  metatarsal. 

The  symptoms  of 
hallux  valgus  vary 
greatly  even  in  the 
cases  uncomplicated  by 
bursitis.  In  the  sim- 
plest cases  there  may 
only  be  a  little  dull 
pain,  due  to  the  more 
or  less  constant  pull  on 
the  inner  side  of  the 
capsule   or   due   to   the 

pressure  of  the  shoe  against  the  exposed  and  enlarged  head  of 
the  metatarsal.  In  other  cases  the  pain  may  be  so  great  as  to 
make  walking  very  difficult.  If  there  is  simple  or  suppurative 
bursitis,  there  will  be  corresponding  signs  of  inflammation  of  the 
soft  parts  with  great  pain  and  tenderness,  somewhat  modified  by 
the  imperfect  drainage  which  often  takes  place  through  a  small 
sinus  (Fig.  298). 

Treatment. — Non-operative  treatment  of  hallux  valgus  is 
palliative,  and  in  the  early  stages,  curative.  Ill-fitting  shoes  should 
be  discarded,  and  broad-toed  shoes  selected  which  fit  snugly 
around  the  instep  and  leave  plenty  of  room  for  the  toes.  Most 
people  consider  such  shoes  ugly,  so  that  they  should  not  be  un- 


Fig.  298. — Hallux  Valgus,  with  Hypertrophy 
of  the  Head  of  the  Metatarsal  and  Suppu- 
rative Bursitis  and  Synovitis.  A  small  rub- 
ber drain  is  in  the  sinus.  Patient  a  man  aged 
thirty-eight  years. 


552      TUMORS   AND    DEFORMITIES   OF   THE   LEG   AND   FOOT 

necessarily  broad.  The  introduction  of  a  toe-post  to  separate  the 
first  toe  from  the  others,  should  not  be  advised ;  for  in  cases  in 
which  the  deformity  is  marked,  operation  is  clearly  indicated. 
High  heels,  by  flexing  the  toes,  (cud  to  increase  any  existing  lat- 
eral deflection  whenever  the  patient  bears  weight  on  the  foot. 

The  patient  should  practise  several  times  a  day  voluntary  con- 
traction  of  the  adductor  muscles  of  the  great  toe.  At  first  this 
may  be  impossible,  hut  repeated  effort  will  soon  restore  the  lost 
power  over  these  muscles.  This  practise  will  tend  to  correct  the 
existing  deformity  ami  also  to  develop  the  fibrous  protection  en 
the  inner  side  of  the  joint.  Bathing  with  cold  water,  rubbing 
with  alcohol,  and  other  measures  of  a  similar  character  are  serv- 
iceable. Counter-irritants,  such  as  guaiacol  or  iodine,  may  lessen 
the  pain. 

Treatment  by  Operation. — Hallux  valgus  in  its  severer  forms 
is  amenable  to  operative  treatment.  A  number  of  methods  have 
been  suggested,  of  which  the  one  described  is  probably  the  simplest 
and  best.  This  conclusion  seems  warranted  both  on  theoretical 
grounds  and  because  of  the  excellent  results  which  follow  it.  It 
is  best  performed  under  general  anesthesia.  An  incision  slightly 
concave  upward  is  made  along  the  side  of  the  joint  at  about  the 
margin  of  the  thick  plantar  skin.  An  incision  so  placed  will  give 
a  scar  too  low  to  be  pressed  against  the  upper  of  the  shoe  and  too 
high  to  be  pressed  against  the  sole  of  the  shoe.  The  incision 
should  be  about  two  inches  in  length.  Skin  flaps — especially  the 
upper  one — are  dissected  free  and  retracted.  The  bursa,  if  in- 
flamed, should  be  dissected  out  and  removed  entirety.  The  capsule 
of  the  joint  is  opened  by  a  longitudinal  incision.  An  estimate 
is  then  made  of  the  amount  of  the  head  of  the  metacarpal  which 
it  will  be  necessary  to  remove  in  order  to  correct  the  jDlane  of  the 
joint  and  to  allow  the  toe  to  lie  in  a  correct  position  without  force. 
The  capsule  should  then  be  reflected  from  such  a  portion  of  the 
metatarsal  and  the  partial  resection  of  the  head  of  the  bone  car- 
ried out.  This  may  be  done  with  a  bone  forceps  or  with  a  small 
chisel.  In  either  case  splintering  of  the  bone  is  to  be  avoided 
by  having  the  tools  sharp  and  by  cutting  only  a  little  of  the  bone 
at  a  time.  The  piece  of  bone  resected  should  be  wedge-shaped, 
the  base  of  the  wedge  being  directed  inward,  but  the  resection 
should  extend  clear  to  the  outer  side  of  the  metatarsal  in  order 


HALLUX   VALGUS 


OOo1 


to  avoid  tension  on  the  external  portion  of  the  capsule  when  the 
toe  is  brought  into  a  correct  position.  Superfluous  knobs  of  bone 
on  its  inner  aspect  should  now  be  chiseled  away,  and  the  cut  sur- 
face of  the  metatarsal,  which  must  now  form  the  joint  with  the 
first  phalanx  should  be  rounded  to  conform  to  the  normal  bone. 
The  phalanx  is  not  hypertrophied  and  should  not  be  cut  into. 
This  will  insure  a  movable  joint  except  in  suppurative  cases  in 
which  the  cartilage  of  the  phalanx  has  sloughed. 

The  cavity  of  the  joint  should  be  irrigated  with  saline  solu- 
tion and  wiped  clean.  If  sufficient  bone  has  been  resected,  the 
position  of  the  toe  can  be  corrected  with  very  little  force.  An 
excess  of  capsule  from  the  inner  side  should  be  removed  by  cut- 
ting out  of  it  a  transverse  ellipse  and  suturing  the  cut  edges.  In 
a  suppurative  case  the 
joint  should  be  drained 
by  a  wick  of  gutta-per- 
cha tissue.  The  skin 
incision  should  be  part- 
ly or  wholly  sutured 
and  a  small  dressing- 
applied,  while  the  toe 
is  held  in  an  overcor- 
rected  position  by  a 
suitably  padded  lateral 
splint. 

This  splint  should 
under  no  circumstances 
touch  the  region  of  the 
joint.  It  should  be  mod- 
erately padded  where  it 
comes  in  contact  with 
the  heel,  and  very 
thickly  padded  opposite 
the  tarsus.  It  should 
then  be  firmly  bandaged 
to  the  foot.  The  toe 
can  then  be  approximated  to  the  splint  more  or  less  according  to 
circumstances.  In  this  manner  the  wounded  or  inflamed  area 
will  not  be  pressed  upon  at  all  (Fig.  299). 


Fig.  299. — Lateral  Splint  for  Holding  the  Toe 
After  Operation  for  Hallux  Valgus. 


551       TUMORS   AND   DEFORMITIES   OF   THE   LEG   AND   FOOT 

The  wound  should  be  entirely  healed  in  from  ten  to  twenty 
days,  and  a  movable  joint  should  be  obtained.  In  favorable  cases 
the  patient  can  go  about  on  crutches  from  the  start. 

"While  such  a  result  may  be  anticipated  in  clean  cases,  and 
even  in  those  in  which  the  infection  is  mild,  there  are  other  cases 
in  which  the  suppuration  of  the  joint  has  already  caused  the  erosion 
of  the  cartilages  and  possible  necrosis  of  some  of  the  bone.  Under 
such  circumstances  free  drainage  must  be  maintained  for  a  con- 
siderable time.  There  will  usually  be  a  sinus,  and  possibly  an 
ulcer,  to  the  inner  side  of  the  joint  which  will  determine  the  site 
of  the  lateral  incision.  Through  this  the  joint  cavity  should  be 
widely  opened,  and  so  much  of  the  head  of  the  metatarsal  bone 
should  be  removed  as  may  be  necessary  to  correct  the  deformity. 
This  gives  the  surgeon  a  good  view  of  the  interior  of  the  joint  and 
of  the  opening  into  an  abscess  cavity,  if  one  has  already  formed, 
as  is  frequently  the  case,  between  the  bases  of  the  first  and  second 
phalanges.  Such  an  abscess  will  require  additional  drainage  on 
the  dorsum  of  the  foot,  or  between  the  first  and  second  toes.  The 
foot  should  be  put  up  in  a  wet  dressing.  A  week  later,  when  the 
acute  symptoms  will  have  subsided  somewhat,  it  will  be  time 
enough  to  apply  the  lateral  splint. 

Hallux  Kigidus. — As  the  name  implies,  this  is  an  affection 
of  the  great  toe,  marked  by  stiffness  of  the  metatarsophalangeal 
joint.  The  toe  may  lie  straight  ahead  or  be  slightly  flexed.  The 
affection  is  often  seen  in  early  adult  life.  It  is  often  associated 
writh  flatfoot.  In  the  later  stages,  the  joint  becomes  distinctly 
thickened,  as  it  does  in  hallux  valgus. 

If  hallux  rigidus  is  an  accompaniment  of  flatfoot,  the  symp- 
'toms  may  disappear  with  the  cure  of  the  flatfoot.  If  this  is  not 
the  case,  the  pain  in  walking  may  be  greatly  relieved  by  stiffening 
the  sole  of  the  shoe  with  leather  or  a  steel  plate,  so  that  the  shoe 
does  not  bend  opposite  the  affected  joint.  If  the  symptoms  are 
extreme,  excision  of  the  joint  or  amputation  of  the  toe  may  be 
necessary. 

Hammer-toe. — Hammer-toe  is  a  deformity  resulting  from 
the  wearing  of  short  shoes.  Usually  only  one  toe  is  affected,  either 
the  second  or  the  third.  Often  the  deformity  exists  in  each  foot. 
It  is  more  often  found  in  slim  persons  with  long  toes. 

The  toe  is  sharply  flexed  at  the  first  phalangeal  joint,  while 


HAMMER-TOE 


555 


the  third  phalanx  may  or  may  not  be  overextended.  There  is 
usually  a  painful  corn  over  the  first  phalangeal  joint.  The  liga- 
ments and  tendons  will  often  be  found  too  short  to  permit  the  toe 
to  be  fully  extended. 

A  hammer-toe  may  be  cured  by  an  incision  across  the  flexor 
side  of  the  first  phalangeal  joint.     This  cut  should  divide  skin, 


Fig.  300. — Interwoven   Adhesive   Strips   for   Correcting   the    Deformity    of 
Hammer-toe  After  Operation. 


flexor  tendons,  and  the  capsule  of  the  joint,  so  that  the  toe  may 
be  fully  straightened  and  easily  kept  straight.  It  is  sometimes 
of  advantage  to  divide  the  extensor  tendon  in  the  middle  of  the 
proximal  phalanx.  The  incision  on  the  flexor  side  of  the  toe  may 
be  partly  or  wholly  closed  by  sutures  inserted  from  side  to  side, 
thus  changing  the  transverse  incision  into  a  longitudinal  one. 

This  little   operation  is  nearly  bloodless,   and   is   easily  per- 
formed with  a  local  anesthetic  on  even  a  sensitive  individual.     A 


550      TUMORS   AND   DEFORMITIES   OF   THE    LEG    AND    FOOT 

light  dry  dressing  should  be  applied  to  the  toe  operated  on,  and 

two  strips  of  adhesive  plaster  should  be  woven  through  the  affected 
toe  and  its  fellows  on  either  side  in  such  manner  as  to  hold  down 
the  first  phalangeal  joint  and  to  hold  up  the  end  of  the  toe 
(Fig.  300). 

This  interweaving  of  adhesive  plaster  is  not  uncomfortable  and 
should  hold  the  toe  perfectly  in  a  correct  position.  It  should  be 
kept  up  for  weeks  if  there  is  any  tendency  toward  the  recurrence 
of  the  deformity. 

The  operation  above  described  is  suited  to  a  toe  with  flexible 
joints  and  plenty  of  skin.  In  long  standing  cases  the  skin  and 
fascia  on  the  under  surface  are  insufficient  to  cover  the  toe  in 
its  extended  position.  In  such  eases  it  is  better  to  resect  the  head 
of  the  first  phalanx  through  a  linear  lateral  incision.  After  the 
bone  has  been  resected  the  flexor  tendons  and  the  deep  fascia  can 
be  divided  transversely  through  the  incision  already  made.  The 
toe  will  then  lie  in  an  extended  position  without  the  use  of  force, 
and  has  only  to  be  kept  there  during  the  healing  of  the  wound. 
The  wound  should  be  sutured  without  drainage. 

If  a  hammer-toe  is  thick  and  painful,  and  if  the  pressure 
upon  the  end  of  the  toe  has  produced  marked  deformity  of  the 
nail,  amputation  of  the  terminal  phalanx  or  the  last  two  phalanges 
may  be  indicated.  This  is  especially  the  case  if  the  patient  is  in 
middle  life  or  beyond.  The  plantar  skin  should  be  preserved  in 
order  to  make  a  thick  and  painless  flap. 

Flatfoot. — In  flatfoot,  two  abnormal  conditions  are  found, 
combined  or  alone — a  weakness  and  sinking  of  the  longitudinal 
arch  of  the  foot  and  a  rigidity  of  the  metatarsotarsal  and  tarsal 
joints.  These  facts  can  be  determined  by  inspection  and  manipu- 
lation of  the  feet,  by  observing  the  effect  of  standing  with  and 
without  resting  the  weight  of  the  body  on  the  suspected  foot,  by  the 
gait,  and  by  noting  the  imprint  of  the  foot  when  weight  is  borne 
upon  it.  The  symptoms  are  pain  in  the  feet  and  legs,  especially 
after  standing,  an  unnatural,  stumpy  gait,  the  patient  not  rising 
on  the  balls  of  the  feet,  and  in  some  cases  swelling  of  the  feet. 

Physical  examination  is  most  important,  Both  feet  and  legs 
should-  be  bared  to  the  knee,  and  the  patient  asked  to  stand  up- 
right, putting  the  weight  first  on  one  foot  and  then  on  the  other. 
If  the  foot  is  merely  weak,  the  arch  will  sink  when  the  weight  is 


FLATFOOT 


557 


placed  upon  it;  if  it  is  also  rigid,  the  breaking  downward  of  the 
arch  will  be  manifest  whether  or  not  the  weight  is  placed  upon  it. 
The  second  test  is  one  of  manipulation.  The  patient's  foot 
should  be  rested  upon  the  examiner's  knee.  If  the  left  foot  is  ex- 
amined, the  doctor's  left  hand  should  grasp  the  heel,  but  the  ball 
of  his  left  hand  should  rest  against  the  center  of  the  areh.     With 


Fig.  301. — Testing  the  Degree  of  Rigidity  in  Flatfoot,  and  Correcting  the 

Deformity. 


his  right  hand  he  should  grasp  the  heads  of  the  metatarsals,  the 
palm  of  his  hand  resting  against  the  outer  border  of  the  foot.  In 
this  manner  he  can  test  the  amount  of  flexibility  of  the  foot,  and 
can  also  estimate  the  amount  of  force  required  to  bring  it  into  a 
normal  position.  By  allowing  his  two  hands  to  sink  between  his 
knees,  he  can  supplement  the  muscular  actions  of  his  arms  by  that 
of  his  thighs,  thereby  greatly  relieving  himself  when  attempting 
to  correct  bimanually  any  existing  deformity  (Fig.  301). 

The  imprint  of  the  foot,  when  weight  is  borne  upon  it,  may 
be  obtained  by  allowing  the  patient  to  step  first  upon  a  wet  towel 
and  then  upon  a  board  or  upon  blotting  paper  laid  on  a  hard  sur- 
face. A  permanent  impression  is  best  obtained  by  inking  a  glass 
plate  with  printer's  ink,  in  the  manner  employed  for  small  printing- 
presses,  allowing  the  patient  to  step  on  the  glass  plate  and  then 


558      TUMORS   AND   DEFORMITIES   OF  THE   LEG   AND   FOOT 

to  step  on  paper.  The  ink  is  readily  washed  from  the  fool  by 
soap  and  water. 

Treatment. — If  the  flatfoot  is  due  to  weakness  alone,  and  is 
of  moderate  degree,  the  patient  should  take  exercises  morning  and 
night,  turning  the  toes  directly  forward  or  slightly  inward,  and 
hearing  the  weight  first  on  the  heels  and  then  on  the  balls  of  the 
two  feet.'  This  should  be  taken  up  gradually  until  it  can  be  done 
thirty  or  forty  times.  The  second  exercise  consists  in  walking 
around  the  room  barefooted,  with  the  toes  turned  in  and  spread 
out  as  much  as  possible,  and  the  weighl  entirely  borne  on  the  balls 
of  the  feet,  the  heels  being  kept  as  high  from  the  floor  as  possible. 
In  the  third  place,  the  patient  should  learn  to  walk  with  the  toes 
straight  ahead.  Patients  with  flat  feet  habitually  turn  the  toes  out- 
ward, to  avoid  lifting  the  weight  of  the  body  on  the  balls  of  the  feet 
as  they  step  forward.     This  faulty  gait  increases  their  deformity. 

The  fourth  suggestion  for  treatment  is  the  elevation  of  the 
inner  half  of  the  sole  of  the  shoe  by  one  or  two  thicknesses  of 
leather.  Both  the  heel  and  the  ball  of  the  shoe  should  be  so  treated 
that  the  plane  of  the  shoe  where  the  foot  rests  upon  it  may  be 
inclined  slightly  outward. 

These  simple  rules,  if  persistently  followed  out,  will  cure  many 
cases  of  flatfoot  due  to  weakness.  If  rigidity  exists,^  correct  rela- 
tion of  the  bones  must  be  brought  about  by  manipulation  before 
the  measures  above  outlined  can  effect  a  cure.  This  manipula- 
tion is  described  above.  It  should  be  performed  at  least  twice  a 
week  by  the  doctor,  until  the  patient  can  voluntarily  bring  the 
foot  into  the  correct  position. 

In  the  more  severe  cases  of  weak  foot,  and  in  almost  all  the 
cases  in  which  rigidity  is  present,  additional  treatment  is  required. 
The  manipulation  above  described  must  be  carried  out  until  the 
rigidity  has  disappeared;  or  if  the  rigidity  is  too  great  to  yield 
readily  to  such  treatment,  or  if  the  pain  will  not  permit  of  the 
employment  of  much  force,  the  patient  should  be  etherized,  the 
deformity  forcibly  corrected,  and  the  foot  put  up  in  a  heavy  plaster 
of  Paris  bandage,  markedlv  inverted,  and  with  as  much  of  an 
arch  given  to  it  as  is  possible  (Fig.  302).  The  patient  should  go 
about  in  such  bandages  from  four  to  eight  weeks.  In  extreme  cases 
it  is  advisable  to  apply  a  second  or  a  third  bandage,  each  time 
some  gain  in  position  being  accomplished.    It  is  worse  than  useless 


FLATFOOT  559 

to  fit  a  brace  to  the  sole  of  the  foot  as  long  as  there  is  rigidity  in 
an  incorrect  position. 

When  the  foot  can  be  brought  into  a  normal  position  a  cast 
should  be  made  of  it  in  gypsum  (see  p.  710),  and  a  steel  support 


Fig.  302. — Markedly  Rigid   Flatfeet   Put    Up    in    a    Corrected  Position  in 
Circular  Gypsum  Splints. 

made  from  the  cast,  to  be  worn  inside  the  patient's  shoe.  Such 
a  brace  will  usually  crack  or  rust  in  six  months  or  a  year,  and 
it  sometimes  requires  the  purchase  of  specially  made  shoes ;  but 
these  are  slight  inconveniences  compared  with  the  disability  caused 
by  well  marked  flatfoot. 


Alio      TUMORS    AND   DEFORMITIES   OF  THE   LEG    AND   FOOT 

In  some  cases  the  wearing  of  braces  for  two  or  three  years  will 
so  correct  the  deformity  thai  the  patient  may  go  through  life  with- 
out braces  and  withoul  special  shoes. 

While  the  treatmenl  of  flatfoot  requires  a  good  deal  of  time 
and  trouble,  there  are  no  patients  who  are  more  grateful  for  the 
relief  tlk'v  obtain  than  these  sufferers. 

Transverse  Flatfoot ;  Sinking  of  the  Transverse  Arch. 
— The  transverse  arch  of  the  foot,  formed  by  the  beads  of  the 
metatarsal  hones,  may  sink,  giving  rise  to  pain  and  disability. 
The  pain  in  some  of  these  cases  has  received  the  special  name  of 
metatarsalgia,  or  Morton's  disease.  It  is  thought  to  be  due  to  an 
abnormal  pressure  of  the  head  of  one  metatarsal  bone  against  an- 
other, or  againsl  the  sole  of  the  shoe.  The  heads  of  these  hones 
normally  form  a  shallow  arch.  It  is  easy  to  see  that  the  displace- 
ment of  one  of  them  may  alter  their  relations.  Sometimes  this 
dis|)l  a  cement  is  permanent,  sometimes  it  only  occurs  when  the 
patient  steps  on  the  foot. 

In  some  cases  a  narrow  shoe,  by  preventing  the  spreading  out 
of  the  bones  which  compose  the  arch,  is  distinctly  more  comfortable 
than  a  broader  shoe.  A  patient  who  lias  observed  this  fact  may 
resent  the  idea  that  the  shoe  lias  anything  to  do  with  the  deformity. 
It  is  none  the  less  true  that  the  wearing  of  short  shoes  and  high 
heels,  by  producing  dorsal  flexion  of  the  toes,  brings  an  undue 
strain  upon  the  transverse  metatarsal  arch,  and  predisposes  it  to 
give  way. 

Treatment. — What  has  been  said  of  exercise  and  manipula- 
tion in  the  treatment  of  flatfoot  is  of  equal  value  in  the  treatment 
of  weakness  of  the  transverse  arch.  If  one  metatarsal  bone  has 
sunk  below  its  proper  jilane,  a  support  should  be  placed  beneath 
it.  This  can  be  made  of  sole  leather  with  a  beveled  edge,  and  glued 
to  the  sole  of  the  shoe,  or  a  steel  brace  can  be  fitted  to  a  gypsum 
cast  made  of  the  sole  of  the  foot.  The  deformity  in  the  cast 
should  be  corrected  by  paring  away  the  projection  which  represents 
the  displaced  metatarsal  bone.  If  rigidity  coexists  with  weakness, 
a  correct  position  of  the  arch  should  be  obtained  before  a  brace  is 
fitted  to  the  foot.  The  brace  need  not  come  so  far  up  on  the 
instep  as  the  brace  made  to  prevent  sinking  of  the  longitudinal 
arch. 

If  a  callus  has  formed  over  the  displaced  metatarsal  bone,  the 


HYPERTROPHY   OP   TOES 


.501 


superfluous  epithelium  should  be  softened  with  salicylic  acid  and 
carefully  peeled  away.  If  such  a  callus  is  recklessly  torn  or  cut 
into,  it  may  form  a  starting-point  for  a  most  troublesome  infec- 
tion and  ulceration  (see  p.  529). 

Painful  Heel. — Policemen,  and  others  who  stand  a  great  deal, 
sometimes  complain  of  severe  pain  in  the  plantar  surface  of  the 
heel.  This  may  be  due  to  flat  foot,  or  simply  to  overuse  of  the 
part,  or  in  some  cases  it  may  be  due  to  inflammation  of  a  small 
bursa.  The  patient  should  be  advised  to  wear  rubber  heels,  and 
if  the  pain  is  localized  in  a  small  area,  the  insole  of  the  shoe 
should  be  cut  away  at  this  point,  or  raised  over  the  rest  of  the 
heel  in  order  to  effect  a  different  distribution  of  pressure. 

CONGENITAL   DEFORMITIES 

Congenital  deformities  of  the  foot  are  analogous  to  those 
of  the  hand,  but  they  are  less  often  the  subject  of  treatment  be- 
cause the  toes  are  not  used  individually. 

Hypertrophy   of  Toe. — Marked  hypertrophy  of  one  or  more 

toes  is  a  condition  which  calls  for  surgical  treatment,  on  account 


Fig.  303. — Congenital  Hypertrophy  of  Second  Toe. 


562      TUMORS  AND  DEFORMITIES  OF  THE  LEG  AND  FOOT 

of  the  awkwardness  due  to  the  great  size  of  the  hypertrophied 
member  (Fig.  303).  Amputation  of  the  superfluous  tissue  is 
called  for,  so  that  the  patient  may  be  able  to  wear  ordinary  shoes, 
and  also  to  reduce  the  risk  of  malignant  degeneration,  which  is 
a  n<>t   wry  unusual  change  in  tissue  of  this  character. 

Supernumerary  Toe. — Supernumerary  toes  are  about  as 
common  as  supernumerary  fingers.  Their  removal,  however,  is 
not  usually  sought  for  unless  they  project  at  an  angle. 


SECTION  VIII 
MINOK  SUEGIOAL  TECHNIQUE 


CHAPTEE    XX 
OPERATIVE  TECHNIQUE 

The  Conditions  of  Operation. — In  no  part  of  the  field  of 
surgery  ought  the  results  obtained  to  be  any  better  than  those 
obtained  in  minor  surgery.  The  patient  who  requires  treatment  of 
this  character,  whether  operative  or  not,  is  usually  in  good  health ; 
there  is  little  shock  or  loss  of  blood  to  be  recovered  from;  and 
nutrition  is  not  disturbed  by  a  long  confinement  to  the  bed.  In 
all  these  respects  the  condition  of  the  patient  is  favorable  to  rapid 
recovery.  If  the  doctor's  work  is  of  the  high  character  which  has 
justly  made  famous  some  other  branches  of  surgery  such  rapid 
recovery  and  without  complications  will  be  assured.  Yet  the  ease 
with  which  primary  union  is  obtained  in  a  small  wound  made 
upon  a  healthy  child  or  young  adult  must  not  be  allowed  to  induce 
careless  methods  of  treatment. 

Asepsis.: — Successful  surgery  is  clean  surgery.  It  is  easy  to 
say  "  the  operation  should  be  performed  with  due  regard  to  the 
principles  of  asepsis,"  and  this  is  literally  true  of  the  smallest 
operation.  But  common  sense  tells  us  that  while  the  same  princi- 
ples underlie  recovery  from  a  prolonged  laparotomy  and  from  a 
scalp  wound,  much  of  the  preparation  which  is  essential  for  the 
former  is  unnecessary  for  the  latter.  A  brief  statement  of  the 
essentials  of  a  clean  minor  operation  is  therefore  desirable. 

The  Operating-room. — The  room  is  not  an  essential.  Good  re- 
sults should  be  obtained  by  the  roadside,  in  a  machine  shop,  or 
barn,  as  well  as  in  the  doctor's  office;  but  those  who  have  much 
work  of  this  sort  to  perform  will  naturally  fit  up  a  room  with  a 
floor  of  tiles  or  hardwood  or  covered  with  linoleum,  so  that  it 
can  be  easily  washed.  It  should  have  a  good  light,  both  natural 
38  .  563 


564  OPERATIVE   TECHNIQUE 

and  artificial  It  should  be  furnished  with  a  table  for  the  patient, 
one  or  two  tables  for  instruments  and  dressings,  two  chairs  or 
stools,  a  case  for  instruments,  a  water-supply,  an  irrigator,  a  slop 
sink,  a  pan  for  boiling  water  and  sterilizing  instruments,  and  a 
steam  sterilizer  for  dressings.  Everything  should  be  of  a  char- 
acter to  .make  it  easily  cleaned.  The  sterilizers  need  not  be 
elaborate.  An  asparagus  boiler  answers  well  for  instruments,  and 
an  Arnold  Steam  Sterilizer  does  well  for  dressings.  Many  prefer 
to  omit  the  latter  and  buy  gauze  ready  sterilized  in  packages. 

Preparation  of  the  Patient — Usually  the  patient  comes  with- 
out preparation,  frequently  soon  after  a  full  meal.  This  really 
makes  little  difference,  even  if  he  is  given  a  general  anesthetic. 
The  danger  from  vomiting  during  anesthesia  is  much  exaggerated. 
Certainly  "  aspiration  pneumonia  "  need  not  be  greatly  feared. 
If  he  vomits,  the  material  should  be  given  free  exit  and  his  mouth 
wiped  out ;  that  is  all. 

The  clothing  should  be  removed  from  the  part  to  be  operated 
on  and  its  vicinity.  If  this  is  not  done  the  patient  is  likely  to  go 
away  with  a  bloody  shirt  or  dress.  It  is  no  excuse  that  the  patient 
is  so  excited  as  not  to  notice  this.  The  doctor  ought  not  to  be 
excited  and  ought  to  notice.  One  ought  not  to  cut  off  clothing 
that  can  just  as  well  be  removed  in  the  usual  way.  If  its  removal 
causes  pain,  that  is  another  matter. 

When  it  can  be  done  readily,  the  patient  should  be  put  in  a 
horizontal  position.  The  most  stolid  appearing  person  may  faint 
unexpectedly.  Many  persons  are  ashamed  to  choose  a  horizontal 
position,  consequently  the  choice  should  not  be  offered  them. 
They  will  lie  clown  readily  if  they  think  this  makes  it  easier  for 
the  doctor — as  it  certainly  does. 

While  the  instruments  are  boiling  the  field  of  operation,  or 
of  the  wound,  as  the  case  may  be,  is  cleansed  as  follows:  It  is 
washed  with  soap,  a  swab  of  absorbent  cotton,  and  hot  water; 
then  with  another  swab  of  cotton  and  a  solution  of  bichlorid  of 
mercury,  1 :  1,000 ;  then  it  is  scrubbed  with  a  swab  of  cotton  wet 
with  alcohol.  If  the  skin  is  very  greasy,  a  swab  wet  with  turpen- 
tine should  precede  the  one  wet  with  alcohol. 

The  wound,  if  one  exists,  or  the  delicate  membranes,  such  as  the 
lining  of  the  eye,  should  be  irrigated  Avith  one  per  cent  saline  solu- 
tion, and  foreign  material  dislodged  by  gentle  washing  with  cotton. 


asepsis  565 

The  vicinity  of  the  operation  should  then  be  covered  with 
sterile  gauze  or  with  towels  wrung  out  of  1  :  1,000  bichlorid  solu- 
tion. Another  such  towel  or  gauze  should  be  spread  on  a  small 
table  for  the  instruments,  sutures,  or  dressings.  Whenever  it  is 
possible  to  do  so,  the  instruments  should  be  prepared  out  of 
sight  and  hearing  of  the  patient  and  before  he  is  brought  to  the 
operating  table.  This  will  avoid  delay  and  the  unpleasant  sug- 
gestions made  by  the  rattling  of  instruments. 

The  Operator's  Hands. — The  operator  next  prepares  his  own 
hands  by  (a)  washing  them  with  soap  and  water,  and  then  with 
a  mixture  of  washing  soda  and  chlorid  of  lime,  freshly  rubbed 
together  with  a  little  water  in  the  palm  of  the  hand,  and  rinsed 
off  with  sterile  water  or  bichlorid  solution;  or  (b)  he  pulls  on 
rubber  gloves  which  have  been  previously  sterilized  or  which  he 
washes  off  carefully  in  the  bichlorid  solution  after  he  has  put 
them  on.  The  smooth  surface  of  a  rubber  glove  can  be  quickly 
freed  from  germs  in  this  manner,  whereas  it  is  a  long  and  tedious 
process  to  render  sterile  the  crevices  in  the  skin  and  about  the 
nails;  or  (c)  having  washed  his  hands  with  soap  and  water,  and 
having  dried  them,  he  keeps  them  absolutely  out  of  the  wound, 
touching  only  the  handles  of  the  instruments  or  the  ends  of 
sutures  and  ligatures  which  will  not  again  pass  through  the  tis- 
sues nor  remain  in  the  wound.  This  last  method  is  the  quickest  of 
all  and  with  a  little  practise  it  is  absolutely  reliable  for  the  ligation 
of  vessels,  suture  of  traumatic  wounds,  removal  of  some  foreign 
bodies,  etc.  It  is  not  suitable  for  cases  in  which  the  diagnosis  is 
obscure  or  in  which  blunt  or  difficult  dissection  may  be  required. 

The  Instruments  and  Solutions.— The  instruments  should  be 
put  on  to  boil  during  the  preparation  of  the  field  of  operation 
and  the  operator's  hands.  They  should  be  boiled  in  plain  water. 
Soda  is  unnecessary  unless  the  water  of  the  locality  contains  some 
ingredients  which  are  injurious  to  metals.  Five  minutes'  boiling 
is  sufficient.  The  water  should  then  be  poured  from  the  pan  in 
which  they  were  boiled,  and  the  instruments  may  be  turned  out 
on  a  piece  of  sterile  gauze  or  allowed  to  lie  in  the  bottom  of  the 
pan  or  tray  for  use.  One  scalpel,  a  curved  blunt  pointed  scissors, 
plain  and  mouse  toothed  forceps,  a  probe,  two  small  sharp  re- 
tractors, two  or  four  artery  clamps,  four  small  needles,  straight 
and  curved,  and  a  hypodermic  syringe  and  needle  are  instruments 


560  opei : ATI \  i •;  technique 

sufficienl  for  mosl  minor  surgical  operations.  Soda  makes  them 
slippery.  If  bandied  in  accordance  with  the  directions  given 
above  they  will  no1  rusl  appreciably.  If  they  are  wrapped  up  in 
a  wet  towel  and  allowed  to  cool  they  may  become  covered  with 
rust  in. a  few  minutes. 

There  should  be  at  band  two  basins,  one  to  contain  the  solu- 
tion of  biehlorid  or  whatever  antiseptic  is  employed;  one  to  contain 
the  one  per  cent  saline  solution.  One  of  these  basins  may  he  used 
for  the  soap  and  water  with  which  the  patient  is  prepared. 

Local  Anesthesia.* — The  anesthesia  of  the  operative  field 
is  of  great  importance.  The  lirst  prick  of  the  needle  is  or  ought 
to  be  the  only  part  of  many  minor  operations  of  which  the  patient 
has  direct  knowledge.  Yet  this  is  seldom  the  case,  because  the 
operator  is  unwilling  to  wait  for  the  cocain  or  other  anesthetic 
to  take  effect,  but  proceeds  with  the  incision  almost  immediately. 
Dilute  solutions  of  cocain,  one  or  at  most  two  per  cent,  are  safer 
and  better  in  most  cases.  An  exception  should  be  made  in  the 
case  of  small  boils  in  an  inelastic  skin,  for  example,  of  the  nose. 
The  additional  distention  caused  by  the  injection  is  very  painful. 
Hence  the  solution  should  be  strong  (four  per  cent),  and  only  a 
drop  or  two  employed.  The  solution  is  best  when  freshly  made. 
A  quarter  grain  hypodermic  tablet  of  cocain  dissolved  in  twenty- 
five  minims  of  sterile  water  makes  a  one  per  cent  solution. 

The  method  of  injection  is  important.  The  needle  should  be 
small  and  sharp.  If  the  skin  is  normal,  one  naturally  makes  a 
small  injection  at  one  end  of  the  future  incision,  either  in  the 
skin,  or  if  the  skin  is  thin,  beneath  it.  An  injection  made  into 
the  skin  raises  a  small  wheal,  possibly  half  an  inch  in  diameter 
(Fig.  304,  1  and  2).  Thirty  seconds  later  a  second  puncture 
of  the  needle  is  made  in  the  far  edge  of  this  wheal,  and  a  second 
injection  is  made;  then  a  third  puncture  and  injection,  and  so 
on.  By  using  a  long  needle  one  can  inject  to  a  greater  distance 
with  one  puncture,  but  this  requires  a  needle  of  larger  caliber.  If 
the  injection  is  made  under  the  skin  the  resulting  swelling  is 
larger  and  more  diffuse — with  less  distinct  edges  (Fig.  304,  3). 

Anesthesia  should  be  tested  by  the  point  of  the  needle.  The 
incision  should  not  be  made  until  all  feeling  of  pain  has  disap- 

*  This  word  should  really  be  analgesia  but  it  is  too  well  known  now  to  be  changed. 


LOCAL   ANESTHESIA 


567 


peared.  If  a  finger  or  toe  is  the  subject  of  operation,  circulation 
should  be  controlled  by  a  bandage  or  rubber  tube  drawn  tightly 
around  it;  anesthesia  will  then  be  complete  and  more  lasting  with 
a  smaller  amount  of  cocain. 

Cocain  is  a  poisonous  drug,  especially  when  injected  into  the 
head,  though  why  its  effects  should  be  so  marked  there  it  is  diffi- 


Fig.  304. — Injection  of  Cocain  for  Local  Anesthesia.  1,  the  wheal  caused  by  the 
first  injection  into  (not  under)  the  skin;  2,  the  wheal  due  to  the  second  injection 
into  the  skin.  The  needle  for  this  injection  is  inserted  in  the  edge  of  the  area 
already  anesthetized.  It  is  shown  in  the  correct  position  for  the  second  injec- 
tion. An  injection  under  the  skin  (subcutaneous  strictly  speaking)  gives  a  dif- 
ferent swelling  as  shown  at  3. 

cult  to  explain.     Many  an  attack  of  supposed  faintness  during 
a  minor  operation  is  really  an  instance  of  acute  cocain  poisoning. 


568  OPERATIVE  TECHNIQUE 

For  this  reason  the  close  should  be  restricted  to  one-quarter  of  a 
grain  if  possible. 

If  an  abscess  is  to  be  opened,  the  method  of  procedure  should 
be  slightly  different.  Injection  should  he  commenced  in  the  rela- 
tively normal  and  elastic  skin  near  one  end  of  the  incision  to  be. 
From  this  puncture  others  should  be  made,  each  nearer  the  center 
of  the  skin  overlying  the  abscess.  Then,  instead  of  continuing 
across  this  much  distended  portion  of  the  skin,  it  is  better  to  begin 
at  the  opposite1  margin  and  again  approach  the  center.  In  this 
manner  anesthesia  is  accomplished  with  the  least  pain. 

Control  of  Hemorrhage. — Assistance  is  usually  Limited  or 
absent,  so  that  the  minor  surgeon  should  control  hemorrhage 
promptly  by  clamp  or  ligature.  One  likes  to  keep  catgut  out  of 
these  wounds,  not  because  the  catgut  is  unsterile,  but  because  there 
may  be  a  few  germs  in  the  wound  for  which  the  catgut  will  be  an 
excellent  nutrient  medium.  Yet  if  a  vessel  bleeds  freely  it  had 
better  he  tied.  A  general  oozing  may  be  checked  by  the  applica- 
tion of  a  swab  of  cotton  Avet  with  a  solution  of  adrenalin  chlorid, 
1 :  5,000. 

Tying  a  Ligature. — Two  points  are  essential  to  a  good  method  : 
The  operator  should  have  a  continuous  grasp  of  both  ends  of  the 
ligature.  That  means  that  he  shall  never  let  go  of  either  end  until 
he  has  secured  a  fresh  hold  upon  it  in  another  place.  The  second 
point  follows  from  the  first,  namely,  that  he  shall  be  able  to  tie 
the  ligature  without  looking  at  it.  He  will  then  not  be  delayed  if 
the  light  is  poor  or  the  thread  becomes  covered  with  blood.  One 
of  the  best  methods  is  as  follows : 

Take  a  piece  of  catgut  eighteen  inches  or  two  feet  long.  Pass 
it  around  the  artery  clamp,  and  hold  both  ends  firmly  with  the 
middle,  ring,  and  little  fingers,  leaving  the  thumb  and  index 
fingers  free  below  the  threads.  The  palms  are  upward  (Fig. 
305,  1).  Pass  the  right  index-finger  over  the  left  string  (2), 
and  bring  it  back  under  the  left  string,  and  poke  the  end  of  the 
finger  under  the  right  string  in  the  space  between  the  right  thumb 
and  middle  finger  (3).  '  Straighten  the  index-finger,  thus  bring- 
ing a  loop  of  the  right  string  up  between  the  index-finger  and  the 
thumb  (J/).  Seize  this  thread  between  the  thumb  and  index-finger 
(5),  and  relax  the  grasp  upon  it  by  the  other  fingers.  Withdraw 
the  thumb  and  index-finger  to  the  right  and  a  crochet  stitch  has 


Fig.  305. — Method  of 


Tying  Ligatures.     For  description  see  page  568. 

569 


570  OPERATIVE   TECHNIQUE 

been  made  by  the  right  string  upon  the  lefl  (<>).  Pull  this  clear 
through,  and  it  becomes  a  half  hitch,  and  can  be  drawn  down 
tight.  A  second  and  a  third  can  be  made  in  the  same  manner; 
or  if  the  operator  fears  a  "  granny  knot,"  a  perfectly  groundless 
fear  by  the  way,  the  process  can  be  reversed  for  the  second  loop, 
and  the  right  string  held  taut,  while  the  left  forefinger  makes  the 
half  hitch. 

Draining  a  Wound. — If  a  wound  is  almost  certainly  clean 
and  hemorrhage  has  been  controlled,  the  skin  should  be  sutured 
without  drainage.  Such  is  or  ought  to  be  the  case  with  most 
of  the  wounds  made  by  the  operator  for  non-suppurative  con- 
ditions. It  is  also  the  case  with  many  traumatic  wounds.  A 
wound  should  not  be  condemned  because  it  contains  coal-dust,  saw- 
dust, and  other  kinds  of  dirt  which  are  incapable  of  sustaining 
bacteria  pathogenic  to  man.  These  foreign  bodies  can  be  re- 
moved, and  even  if  some  particles  remain  primary  union  is  not 
impracticable. 

If  a  wound  has  been  made  by  a  butcher's  knife,  or  by  a  stable 
fork,  or  in  a  machine-shop,  where  animal  fats  are  used  as  lubri- 
cants, the  possibility  of  suppuration  is  far  greater.  In  such  cases, 
as  well  as  in  ragged  wounds  and  other  wounds  in  which  oozing 
of  blood  seems  probable,  a  drain  should  be  employed.  This  drain, 
while  keeping  open  a  way  for  the  escape  of  fluid,  must  be  so 
placed  and  must  be  of  such  a  character  that  it  is  easily  removed 
and  leaves  a  minimum  of  gaping  of  the  suture  line.  Usually 
the  wound  in  such  a  case  should  be  fully  sutured,  but  the  inter- 
rupted stitches  employed  should  not  be  too  close,  and  the  drain 
should  be  so  small  as  to  lie  readily  between  two  stitches.  A  flat 
strip  of  gutta-percha  tissue,  one  inch  wide  and  three  inches  long, 
twice  folded  on  itself,  so  that  it  shall  be  only  one-quarter  of  an 
inch  wide,  answers  the  requirements  admirably.  It  can  then  be 
doubled  and  pushed  in  by  a  flat  probe  (Fig.  306).  As  the  probe 
is  withdrawn  it  should  be  rotated  to  free  it  from  the  tissue, 
which  may  otherwise  stick  to  it  and  be  pulled  out  of  the  wound. 
A  bundle  of  horsehairs,  twisted,  tied,  and  doubled  on  itself, 
makes  another  good  drain.  It  is  stiff  enough  to  insert  without 
a  probe.  If  either  of  these  drains  is  removed  in  two  days 
there  will  be  so  little  additional  granulation  in  its  site  that 
the  scar  is  not  visibly  increased  thereby.     Hence  a  small  drain 


DRAINING  A   WOUND 


571 


should  be  employed  in  doubtful  cases;  for  if  fluid  is  allowed  to 
collect  in  the  wound,  and  has  afterward  to  be  evacuated,  the 
resulting  scar  will  be  greater  than  when  a  drain  of  this  character 
is  employed. 

In  a  third  class  of  cases  suppuration  exists,  and  drainage  is 
used  to  provide  for  the  escape  of  pus.  A  great  mistake  is  made 
in  the  use  of  dry  gauze  in  such  cases.  The  very  fact  that  the 
wound  is  small  and  the  discharge  slight  adds  to  the  risk.     The 


Fig.  306. — Drains  for  Clean  and  Suppurating  Wounds.  A,  Flat  gutta-percha 
drain  folded  on  a  probe  ready  for  insertion ;  B,  a  piece  of  gutta-percha  tissue  of 
the  same  size  as  A;  C,  horsehair  drain;  D,  soft  rubber  tubes  of  various  sizes;  E, 
cigarette  drain  of  gauze  in  a  rubber  finger  cot;  F,  cigarette  drain  of  gauze  and 
gutta-percha  tissue.  At  the  right,  a  piece  of  gutta-percha  tissue  and  a  piece  of 
gauze  each  the  size  of  those  from  which  the  drain,  F,  was  made. 


pus  soaks  into  the  drain,  dries  on  its  outside,  and  seals  up  the 
wound  with  a  tough  and  impervious  glue.  The  abscess  cavity 
is  reestablished,  the  bacteria  flourish,  and  the  patient  suffers. 
Over  and  over  again  I  have  seen  patients  so  treated  come  back 
with  a  more  extensive  cellulitis  than  when  the  abscess  was  first 
opened.  For  a  few  hours  they  had  relief  due  to  the  evacuation 
of  the  pus,   then   drainage  ceased  and  symptoms   recurred.      It 


572  OPERATIVE   TECHNIQUE 

makes  no  difference  whether  or  not  the  gauze  is  impregnated  with 
some  antiseptic;  drainage  is  a  question  of  physics  not  of  chem- 
istry. 

There  are  two  ways  to  insure  perfect  drainage  in  a  small  sup- 
purating wound:  One  is  to  use  a  material  for  drainage  which  will 
not  adhere  to  the  wound,  such  as  guttapercha  or  rubber;  and 
the  other  is' to  keep  the  wound  moist.  A  tint  gutta-percha  drain 
of  appropriate  size  may  be  used;  or  if  it  is  desired  to  keep  the 
edges  of  the  wound  further  apart  the  gutta-percha  tissue  may  be 

loosely  wrapped  around  a  wick  of  gauz< the  so-called   "cigarette 

drain''  (Fig.  0O6).  A  rubber  finger  cot,  from  which  the  tip 
has  been  cut,  makes  an  excellent  sheath  for  the  wick  of  gauze. 
In  a  few  cases  rubber  tubes  are  used  as  drains,  either  because  a 
large  flow  of  pus  is  anticipated,  or  because  it  is  desirable  to  main- 
tain an  opening  of  a  fixed  size.  A  soft  rubber  catheter  makes  a 
good  drain  in  these  cases.  Its  rounded  end  facilitates  its  inser- 
tion in  subsequent  dressings. 

Suturing. — The  wounds  after  minor  operations  are  best  closed 
by  interrupted  stitches  or  a  subcuticular  suture.  The  saving  of 
time  by  the  employment  of  a  continuous  suture  of  the  skin  has 
little  value  compared  with  the  desirability  of  accurate  approxima- 
tion of  the  edges  of  the  skin  in  exposed  portions  of  the  body ;  and 
this  is  more  easily  obtained  by  one  of  the  methods  above  men- 
tioned. 

The  interrupted  suture  is  too  well  known  to  need  description, 
but  it  is  not  always  employed  to  the  best  advantage.  To  obtain 
a  minimum  of  scar  the  sutures  should  not  be  too  tightly  drawn ; 
they  should  be  equally  deep  on  both  sides  of  the  incision ;  they 
should  be  of  very  fine  thread  or  horsehair,  and  they  should  be 
removed  in  two  or  four  days.  To  say  that  a  stitch  is  equally 
deep  in  both  edges  of  the  wound  means  that  the  vertical  distance 
from  the  surface  of  the  skin  to  the  point  where  the  needle  entered 
or  emerged  from  the  cut  surface  is  the  same  on  both  surfaces  of 
the  wound.  If  this  is  not  the  same  on  both  sides,  one  edce  of  the 
skin  will  lie  above  the  other,  and  the  scar  will  be  proportionately 
increased. 

Fine  black  sewing  silk  and  horsehair  are  the  ideal  materials 
for  interrupted  skin  sutures.  They  are  cheap,  and  can  be  sterilized 
by  boiling  with  the  instruments.     To  avoid  handling,  the  needles 


SUTURING 


571 


sliould  be  threaded  before  boiling,  and  secured  in  a  strip  of  muslin 
by  catching  up  a  thread  in  three  or  four  places  (Fig.  ->(>7). 

As  stated  above,  the  strain  upon  a  suture  should  be  kept  at  a 
minimum  in  order  to  avoid  a  scar  due  to  the  stitches  cutting 
through  the  skin ;  yet  there  are  some 
instances  in  which  tension  is  neces- 
sary to  bring  together  the  edges  of 
a  wound.  This  should  be  relieved 
by  undermining  the  skin  for  some 
distance,  and  by  distributing  the 
strain  through  a  large  number  of 
fine  stitches.  It  is  well  to  know  how 
to  insert  a  suture  under  such  cir- 
cumstances if  no  assistant  is  at  hand 
to  prevent  the  first  knot  from  slip- 
ping. 

To  tie  a  knot  under  tension  of 
the  tissues,  make  two  half  hitches 
with  one  end,  holding  the  other  taut. 
While  still  keeping  the  second  end 
taut,  slide  the  half  hitches  down 
snugly  upon  the  tissue  to  be  tied. 
They  will  always  remain  in  place 
temporarily.  jSTow  hold  the  first 
end  taut,  and  loop  the  second  end 
once  about  it.  Slide  this  half  hitch 
down  upon  the  two  already  in  place. 
This  makes  the  knot  permanent. 
Xeither  end  can  slip  on  the  other, 
since  each  makes  a  loop  about  the 
other. 

The  subcuticular  suture  is  an  ex- 
cellent one  for  exposed  portions  of 
the  body,  especially  when  the  possi- 
ble strain  on  the  wound  makes  it 
desirable  to  leave  the  suture  in  place 
more  than  four  clays.     It  should  be 


Fig.  307. — Fixe  Black  Silk  and 
Horsehair  Threaded  in 
Straight  and  Curved  Skin 
Needles.  The  needles  at  the 
right  with  bent  points  are  espe- 
cially good  for  subcuticular  su- 
tures. 


of  strong  horsehair   or 
boiled  without  injury. 


silkworm   gut.      Both   materials   can   be 
The  insertion  of  the  suture  is  much  fa- 


574  OPERATIVE  TECHNIQUE 

cilitated  by  the  use  of  a  Hagedoru  needle  with  a  bent  point,  as 
suggested  by  Dawbarn  (Fig.  307,  the  needles  on  the  right).  If 
one  has  an  assistant  he  inserts  a  sharp  hook  or  one  prong  of  the 
retractor  in  each  end  of  the  wound,  and  pulls  steadily.  This  fixes 
the  skin  edges  so  that  the  operator  can  easily  pass  the  needle  into 
and  out  of  one  skin  edge  and  then  the  other.  It  makes  little 
difference  whether  these  "  bites  "  of  the  skin  are  wholly  within 
the  skin  (intracuticular)  or  partly  beneath  it  (subcuticular). 
They  should  be  placed  close  together  to  prevent  gaping  of  the  skin. 
At  the  beginning  and  end  of  the  suture,  the  thread  comes  to  the 
surface,  where  it  is  secured  by  pinching  a  split  shot  upon  it.  The 
skin  should  be  slightly  puckered  along  the  suture.  At  the  end 
of  five  or  seven  days  the  suture  will  be  loose  in  the  skin.  One 
shot  is  then  cut  off  and  the  suture  is  pulled  out.  The  shot  are  not 
indispensable.  A  large  knot  in  the  suture  answers  the  same  pur- 
pose, or  it  may  be  tied  around  a  bit .  of  gauze. 

Minute  clawlike  metallic  hooks  are  sometimes  used  upon  sen- 
sitive patients  in  place  of  sutures,  to  close  traumatic  wounds. 

Dressings  for  Wounds. — There  are  three  dressings  which 
are  especially  adapted  to  use  upon  small  wounds,  viz.,  the  dry 
gauze  dressing,  the  cotton  collodion  dressing,  and  the  wet  dressing. 

Dry  Gauze  Dressing. — This  consists  of  a  piece  of  sterile  gauze 
folded  several  times  so  as  to  have  from  four  to  twenty  thicknesses. 
It  need  not  extend  more  than  half  an  inch  beyond  the  wound  in 
any  direction.  For  a  sutured  incision  it  need  not  be  wider  than  the 
finger.  It  is  held  in  place  by  strips  of  adhesive  plaster,  which  are 
so  applied  that  they  hold  together  the  edges  of  the  wound  and  take 
some  of  the  tension  from  the  sutures.  These  strips  should  be 
separated  by  a  little  distance,  so  that  evaporation  may  not  be 
interfered  with.  The  whole  dressing  may  be  bandaged  in  position, 
to  give  greater  security. 

The  dry  gauze  dressing  is  suited  to  sutured  wounds,  whether 
traumatic  or  operative.  It  should  not  be  applied  to  raw  surfaces 
nor  to  suppurative  wounds. 

Cotton-Collodion  Dressing. — This  is  a  convenient  form  of  dress- 
ing for  very  small  aseptic  wounds,  especially  when  they  are  so 
placed  that  adhesive  strips  will  not  adhere,  or  they  or  a  bandage 
are  unnecessarily  disfiguring.  This  is  true  of  many  wounds  of  the 
scalp  and  face.    The  dressing  is  applied  as  follows :  All  oozing  from 


OPENING  AN  ABSCESS  575 

the  wound  is  stopped.  If  necessary  to  accomplish  this,  a  dry  gauze 
dressing  and  bandage  are  first  applied  for  a  few  minutes.  A  wisp 
of  dry  absorbent  cotton  is  then  laid  across  the  wound,  and  the 
free  ends  of  the  fibers  are  painted  from  the  center  with  a  camel' s- 
hair  brush  and  flexible  collodion.  When  they  have  been  firmly 
pasted  to  the  skin,  the  surplus  cotton  is  picked  away  a  few  threads 
at  a  time,  until  just  enough  remains  to  cover  the  wound.  The  free 
ends  of  this  wisp  and  both  sides  are  then  pasted  to  the  skin  by 
sweeps  of  the  brush  from  the  center  outward.  If  the  dressing 
is  too  thin  or  stains  through,  a  second  wisp  of  cotton  may  be 
applied  over  the  first.  The  cotton  in  contact  with  the  wound  should 
never  be  saturated  with  collodion,  but  should  always  be  dry  when 
applied  so  that  it  may  absorb  a  few  drops  of  blood  readily,  as  other- 
wise these  will  work  their  way  out  to  the  edge,  thereby  loosening 
the  dressing. 

Wet  Dressing. — A  wet  dressing,  for  use  upon  raw  and  granu- 
lating surfaces  and  over  suppurating  wounds,  consists  of  a  pad  of 
absorbent  gauze  of  suitable  size,  moistened  by  some  antiseptic  solu- 
tion, and  held  in  place  by  a  gauze  bandage.  The  antiseptic  is  not 
for  the  purpose  of  killing  germs  in  the  wound,  but  to  prevent 
irritating  and  foul  smelling  fermentation  in  the  discharge.  Hence 
it  need  not  be  a  strong  one.  Creolin  1 :  200,  or  bichlorid  1 :  5,000, 
or  borolyptol  1 :  8  are  all  satisfactory  solutions  for  the  purpose. 
The  dressing  should  be  moistened  with  water  every  few  hours. 
This  is  better  than  covering  the  dressing  with  an  oiled  silk  or 
rubber  protective,  which  macerates  the  skin  unnecessarily. 

Other  forms  of  dressing  for  use  upon  ulcerating  surfaces,  etc., 
are  described  in  the  treatment  of  these  special  lesions  in  the  earlier 
chapters  of  the  book. 

Opening  an  Abscess. — In  opening  an  abscess  it  is  important 
to  make  the  incision  through  the  best  point  for  drainage ;  to  make 
it  of  the  proper  length,  neither  too  long  nor  too  short,  and  to 
spare  the  patient  unnecessary  pain.  In  some  cases  the  site  and 
length  of  the  incision  can  be  determined  by  inspection  and  pal- 
pation. The  appearance  of  the  skin  often  indicates  where  the  pus 
is  trying  to  work  its  way  to  the  surface.  In  other  cases  palpation 
will  determine  this.  The  center  of  a  large  collection  of  pus  near 
the  surface  is  softer  than  the  indurated  periphery,  whereas  the 
reverse  is  true  of  a  small  collection  of  pus  in  an  area  of  cellulitis. 


576  OPERATIVE   TECHNIQUE 

Then  the  purulenl  focus  feels  more  resistanl  than  the  surrounding 
tissues.  One  can  sometimes  infer  the  length  of  incision  necessary 
from  the  extent  of  the  swelling.  Such  an  inference  is  often  unre- 
liable, and  it  is  quite  unnecessary  to  depend  on  it,  since  the  decision 
can  be  made  more  safely  as  soon  as  the  abscess  cavity  has  been 
eiil    into. 

The  proper  method  of  anesthetizing  the  skin  overlying  an  ab- 
scess  has  been  described  on  page  506.  If  the  abscess  is  small,  a 
spray  of  ethy]  chlorid  may  be  used  to  freeze  it.  This  is  less 
satisfactory  than  cocain,  since  the  sensation  returns  so  quickly 
thai  the  patient  sutlers  intensely  for  a  few  minutes.  Ethy]  chlorid 
used  In  benumb  the  site  of  the  first  injection  of  cocain  is  salis- 
factory. 

When  the  skin  has  been  anesthetized,  a  fine  pointed  scalpel  is 
thrusl  directly  into  the  abscess.  The  short  incision  thus  made  is 
then  extended  in  one  or  both  directions,  according  to  the  extent  of 
the  cavity  of  the  abscess  and  the  importance  of  the  structures  which 
will  have  to  be  divided.  It  is  a  safe  plan  to  make  the  incision 
equal  in  length  to  the  diameter  of  the  cavity  of  the  abscess.  In 
case  of  a  small  abscess  it  should  be  a  little  longer,  and  in  case  of 
a  large  abscess  it  need  not  be  so  long.  It  is  well  to  remember  that 
the  edematous  skin  will  shrink  after  the  abscess  is  opened,  so  that 
an  incision  an  inch  long  at  the  time  it  is  made,  may  be  only  half 
an  inch  long  the  next  day. 

The  full  length  of  the  incision  should  be  maintained  by  drains 
or  gauze  packing  for  several  days.  It  is  an  exhibition  of  bad 
judgment  to  open  an  abscess  by  a  two  inch  incision  and  sew  up  half 
of  it  or  allow  it  to  close  at  once  by  granulations.  It  is  another 
matter  if  one  needs  the  extra  cut  in  order  to  search  for  a  foreign 
body  or  to  explore  some  deep  recess— we  are  here  speaking  of 
minor  surgery.  When  granulations  form  the  drain  may  be  rapidly 
shortened. 

As  soon  as  an  abscess  cavity  is  opened  freely  the  pus  will  escape. 
Squeezing  the  tissues  to  hurry  it  up  does  no  good,  and  may  do 
harm.  Irrigation  with  saline  solution  or  a  very  mild  antiseptic 
does  not  irritate  the  tissues  and  will  keep  the  dressing  from  being 
at  once  soaked  full  of  pus. 

Removal  of  a  Tumor. — Suppose  the  skin  to  have  been 
cleansed  and  the  line  of  incision  rendered  painless  by  injections 


SKIN-GRAFTING  577 

of  a  local  anesthetic  as  previously  described.  If  a  portion  of  skin 
is  to  be  removed,  the  exact  incision  should  be  marked  out  with 
a  scalpel.  After  the  skin  has  been  cut  through  retraction  takes 
place,  which  may  make  it  difficult  to  determine  just  how  much 
should  be  removed.  If  the  incision  is  linear,  this  precaution  is 
unnecessary.  The  knife  blade  should  be  in  a  plane  perpendicular 
to  the  surface.  A  beveled  incision  is  not  usually  desirable.  The 
entire  thickness  of  the  skin  should  be  divided  throughout  the  whole 
line  of  incision  before  any  attempt  is  made  to  reflect  the  flaps.  If 
the  tumor  is  in  the  skin,  it  is  next  lifted  up,  and  the  tissue  at 
its  base  divided ;  vessels  are  ligated,  the  edges  of  the  skin  freed 
from  the  deeper  tissues  for  a  sufficient  distance  to  permit  them 
to  be  brought  together  without  undue  strain,  and  the  sutures 
inserted. 

This  dissection  of  the  flaps  is  of  great  importance,  since  it 
materially  increases  the  elasticity  of  the  skin. 

The  shape  of  the  portion  of  skin  that  is  sacrificed  will  depend 
more  or  less  on  the  shape  of  the  tumor.  When  circumstances  per- 
mit, the  shape  should  be  elliptical,  so  that  sutures  may  leave  a 
linear  scar.  If  the  area  is  to  be  skin-grafted,  it  makes  no  differ- 
ence what  shape  it  is. 

If  the  tumor  is  beneath  the  normal  skin,  so  that  the  latter  need 
not  be  sacrificed,  a  linear  incision  over  the  center  of  the  tumor  is 
the  best  to  use.  Curved  incisions  often  heal  with  a  very  prominent 
scar.  After  the  flaps  of  skin  are  dissected  free  and  retracted,  the 
tumor  is  exposed.  Its  removal  is  facilitated  if  one  frees  it  first 
on  one  side  and  then  upon  the  other.  This  enables  the  operator 
partially  to  lift  it  from  the  wound  and  so  the  better  to  expose  the 
base  where  the  most  difficult  dissection  lies.  A  cystic  tumor 
should  usually  be  split  open  before  removal  (see  p.  447). 

Skin-Grafting. — The  success  of  skin-grafting  depends  largely 
upon  the  care  with  which  the  grafts  are  handled  at  the  time  of 
operation  and  subsequently.     There  are  three  distinct  methods. 

Minute  grafts  may  be  obtained  either  by  snipping  bits  out  of 
the  skin  or  by  scraping  and  macerating  particles  from  the  outer 
layers  of  thick  epidermis.  They  have  not  generally  yielded  good 
results.  The  little  islands  of  epidermis  which  they  produce  will 
often  melt  away  unless  the  epidermis  growing  from  the  side  of  the 
ulcer  reaches  and  surrounds  them. 


578  OPERATIVE  TECHNIQUE 

Thiersch  Grafts. — Sheets  of  skin  shaved  off  with  a  razor,  and  of 
sufficient  thickness  to  include  the  deeper  layers  of  the  epidermis 
and  possibly  some  of  the  dermis  itself  (so-called  Thiersch  grafts) 
huve  yielded  far  better  results.  The  site  from  which  the  grafts  are 
taken  should  be  cleansed  with  soap  and  hot  water  and  washed  with 
sterile  normal  salt  solution  (.8  per  cent).  The  anterior  surface  of 
the  thigh  or  the  outer  side  of  the  upper  arm  are  favorite  places 
from  which  to  take  grafts.  The  skin  should  be  drawn  tight  and 
smooth  with  the  fingers  or  hooks.  With  a  sharp  razor,  preferably 
ground  flat  on  its  under  surface,  strips  of  skin  an  inch  wide  and  an 
inch  or  more  in  length  and  of  a  fairly  uniform  thickness  can  be 
shaved  off.  The  surface  to  which  these  are  to  be  applied  should  be 
fresh,  but  should  be  wiped  free  from  blood.  If  it  is  a  freshly  made 
wound,  hemorrhage  should  first  be  controlled  by  pressure  as  a  blood 
clot  under  a  graft  will  absolutely  prevent  its  union.  If  the  surface 
is  a  granulating  one,  the  granulations  may  be  shaved  off  with  a 
razor  or  simply  wiped  with  sponges  wrung  out  in  hot  sterile  saline 
solution  until  the  granulations  are  clean  and  fresh.  Here,  too, 
oozing  of  blood  must  be  at  a  standstill  before  the  grafts  are  applied. 
As  the  grafts  have  a  tendency  to  shrink  even  though  kept  moist,  it 
is  necessary  that  they  should  fully  cover  the  surface.  Over  them 
may  be  laid  strips  of  rubber  tissue  which  are  to  be  covered  with 
compresses  constantly  kept  moist  with  saline  solution,  or  the  tissue 
may  be  omitted  and  the  compresses  laid  directly  on  the  grafts.  In 
either  case  light  pressure  should  be  maintained  by  a  bandage  in 
order  to  insure  a  continuous  application  of  the  grafts  to  the  under- 
lying surface.  Some  surgeons  do  not  apply  any  dressing  whatever 
for  several  hours,  so  that  the  drying  of  the  serum  shall  firmly 
attach  the  graft  to  the  underlying  granulations.  After  that  a 
dressing  of  dry  or  moist  gauze  or  rubber  tissue  is  applied. 

The  subsequent  treatment  varies.  The  dressing  may  be  changed 
daily,  great  care  being  observed  to  keep  the  grafted  area  con- 
stantly moist  and  protected  from  any  pressure  which  would  cause 
the  graft  to  slip.  Another  plan  is  to  change  the  dressing  in  three 
or  four  days.  Still  another  plan  is  to  cover  the  grafts  with  moist 
or  dry  gauze,  and  not  to  change  the  dressing  for  two  or  three 
weeks.  Some  surgeons  apply  a  plaster  of  Paris  bandage  to  pro- 
tect the  part  from  injury. 

It  will  be  evident  in  three  or  four  days  whether  the  grafts  have 


SKIN-GRAFTING  579 

become  attached,  but  even  those  which  appear  to  be  loose  should 
not  be  too  hastily  removed,  since  their  deeper  portions  may  have 
united  with  the  underlying  granulations.  In  a  week  or  more  the 
grafts  and  portions  of  graft  which  have  not  attached  themselves 
will  have  become  disintegrated,  or  will  be  washed,  away  with 
the  pus. 

The  new  skin  obtained  by  minute  or  Thiersch  grafts  will 
never  be  the  equal  of  normal  skin.  It  is  easily  distinguished  from 
the  surrounding  skin  years  afterward.  It  may  resemble  the  sur- 
rounding skin  under  ordinary  circumstances,  but  it  does  not  react 
in  the  same  way  to  temperature  changes.  In  this  respect  Wolfe 
grafts  and  plastic  operations  are  superior  to  Thiersch  grafts. 

Wolfe  Grafts. — The  third  method  of  skin-grafting  consists  in 
the  use  of  grafts  composed  of  the  entire  thickness  of  the  skin.  In 
some  instances  success  has  followed  this  method  when  a  graft  eight 
inches  long  and  two  and  a  half  wide  has  been  employed.  The 
names  of  Wolfe  and  also  of  Krause  have  been  given  to  this  method 
of  grafting.  These  large  grafts  are  nourished  at  first  by  effusion, 
and  then  minute  vessels  make  their  way  into  the  grafts,  and  in 
some  instances  communicate  with  the  vessels  already  existing. 

The  technique  is  similar  to  that  employed  for  applying  a 
Thiersch  graft.  Asepsis  without  the  use  of  germicidal  solution 
and  the  control  of  hemorrhage  by  pressure  are  important  points. 
The  grafts  should  be  freed  of  fat.  They  may  be  stitched  into 
position,  but  this  is  not  absolutely  necessary.  It  is  of  the  utmost 
importance  that  the  grafts  should  not  be  moved  for  several  days. 
Some  operators  apply  dry  sterile  gauze,  and  do  not  change  it  for 
weeks  unless  there  is  a  purulent  discharge.  Before  attempting  to 
remove  the  dressing,  the  part  should  be  soaked  for  an  hour  in  warm 
boracic  acid  solution.  Other  operators  cover  the  grafts  with  rubber 
tissue  and  moist  gauze. 

According  to  the  results  which  have  been  reported,  one  may 
expect  success  with  about  three-fourths  of  the  grafts  employed. 
Some  of  the  grafts  attach  themselves  in  part,  other  parts  becoming 
necrotic.  Equally  good  results  have  been  obtained  by  using  the 
skin  of  a  healthy  person  who  has  died  from  an  accident  only  an 
hour  or  so  previous. 

If  a  Wolfe  graft  once  becomes  united,  it  is  far  superior  to  a 
Thiersch  graft.  It  has  all  of  the  characteristics  of  normal  skin, 
39 


580  OPERATIVE  TECHNIQUE 

and  prevents  in  great  measure  the  contraction  of  the  underlying 
scar  tissue.  Hence,  Wolfe  grafts  arc  especially  serviceable  to  cover 
defects  about  the  joints. 

Plastic  Operations. — Plastic  operations  are  performed  in 
order  to  hasten  the  healing  of  wounds  and  to  prevent  or  remove 
deformities-  of  various  kinds.  They  owe  their  success  to  the  abun- 
dant blood-supply  of  the  skin  as  well  as  to  its  great  elasticity. 
On  this  account  flaps  with  a  comparatively  small  pedicle,  especially 
if  the  pedicle  is  directed  toward  the  artery  which  supplies  the  tissue 
of  the  flap,  will  maintain  their  vitality,  while  the  elasticity  of  the 
skin  enables  the  operator  to  stretch  one  side  of  the  wound  far 
more  than  the  other  without  producing  a  difference  in  tension 
which  will  be  noticeable  after  a  few  days  or  weeks.  The  pedicle 
of  a  flap  may  even  be  bent  at  a  fairly  sharp  angle  with  the  assur- 
ance that  the  "  kink "  in  the  skin  thus  formed  will  probably 
disappear  entirely,  or,  if  a  surplus  remains,  it  can  readily  be 
removed  at  a  subsequent  operation. 

Plastic  surgery  naturally  finds  its  chief  field  upon  the  face. 
To  cover  a  considerable  defect  in  the  skin  of  this  region  is  a 
problem  which  has  called  forth  many  ingenious  operations,  all  of 
which  are  dependent  on  one  or  more  of  the  following  three  meth- 
ods :  By  the  first  method  a  tongue-shaped  flap  is  turned  back  over 
the  defect  so  that  it  is  wrong-side  out.  This  method  is  especially 
of  use  about  the  nose,  where  it  is  desirable  to  form  a  nasal  cavity 
lined  with  epithelium.  By  the  second  method  flaps  of  various 
shapes  are  rotated  about  their  own  pedicles  in  the  plane  of  the 
surface  of  the  skin.  The  third  method  depends  upon  the  elasticity 
of  the  skin.  By  it  an  incision  is  made  straight  away  from  the 
defect  for  an  inch  or  more.  The  skin  and  subcutaneous  tissue 
on  one  side  of  the  wound  is  freed  from  the  underlying  tissues, 
and  drawn  along  until  it  either  closes  the  defect  or  is  stretched  as 
far  as  seems  prudent.  If  two  parallel  incisions  are  made,  the 
intervening  skin  can  be  stretched  even  further.  If  tension  is 
great  a  large  number  of  fine  sutures  are  more  favorable  to  vitality 
than  a  few,  since  they  divide  the  strain  among  them,  and  no  one 
of  them  is  so  likely  to  shut  off  circulation  or  to  cut  through  the 
skin. 

Infection  from  operations  of  this  character  is  of  rare  occur- 
rence.    It  is  practically  impossible  to  make  some  of  these  wounds 


LUMBAR   PUNCTURE 


581 


aseptic  or  to  keep  them  so,  but  the  abundant  blood-supply  prevents 
the  spread  of  germs  in  the  living  tissues  in  the  great  majority 
of  cases.  The  dressing  should  be  changed  not  later  than  the  second 
day,  and  if  any  inflammation  shows  itself  about  the  stitches  the 
wound  should  be  frequently  cleansed  with  a  mild  antiseptic  solu- 
tion; but  enough  stitches  should  be  left  to  keep  the  flaps  in  posi- 
tion unless  the  inflammation  assumes  a  serious  character.  Even 
if  two  or  three  stitch  abscesses  occur,  it  is  usually  possible  to  post- 
pone removal  of  the  last  of  the  stitches  until  the  flaps  have  united 
so  firmly  as  to  assure  the  success  of  the  operation.  The  develop- 
ment of  erysipelas  in  the  wound  is  a  serious  matter,  for  it  is  likely 
to  proceed  at  once  to  deeper  layers ;  and  even  if  it  does  not  cause 
the  death  of  the  patient,  the  success  of  the  operation  is  eliminated. 
Lumbar  Puncture. — As  the  usefulness  of  lumbar  puncture, 
both  for  purposes  of  diagnosis  and   as  a  means  of  injecting  an 


Fig.  308. — Diagrammatic  Sagittal  Section  of  the  Lumbar  Spine,  Showing  the 
Necessary  Inclination  of  the  Needle  for  Lumbar  Puncture.  This  figure 
also  shows  the  thick  ligaments  which  would  have  to  be  traversed  if  the  needle 
were  inserted  in  the  median  line. 


anesthetic,  has  been  well  established,  a  description  of  the  tech- 
nique is  advisable.  In  the  first  place,  one  should  rid  himself  of  the 
idea  that  it  is  a  difficult  procedure ;  it  is,  on  the  contrary,  very  easy. 
In  the  lumbar  portion  of  the  vertebral  column  the  spinous  proc- 


:»s_' 


OPERATIVE   TECHNIQUE 


esses  project  only  slightly  downward,  so  that  there  is  a  distinct 
gap  between  them.  This  gap  is  filled  with  ligaments.  To  pass  a 
needle  into  the  spinal  canal  in  the  median  line  it  would  be  neces- 
sary to  force  it  through  about  an  inch  of  superspinous  and  inter- 
spinous  ligaments  (Fig.  308).     One  avoids  this  by  inserting  the 


Fig.  309. — Transverse  Section  of  the  Lumbar  Spine  at  the  Level  of  the  Third 
Intervertebral  Disk,  Showing  the  Insertion  of  the  Needle  for  Lumbar 
Puncture.  A  slightly  increased  inclination  of  the  needle  is  better.  It  should 
be  directed  toward  the  center  of  the  spinal  canal. 


needle  about  half  an  inch  to  the  right  or  left  of  the  median  line 
(Fig.  309).  The  needle  should  then  be  aimed  so  that  its  point 
will  strike  the  median  plane  about  an  inch  and  a  half  from  the 
posterior  surface.  As  the  lumbar  cord  does  not  extend  as  low  down 
as  the  bottom  of  the  second  lumbar  vertebra,  there  is  no  risk  of 
puncturing  the  cord  with  the  needle  unless  one  inserts  it  above 
the  second  lumbar  interspace.  As  a  means  of  obtaining  spinal 
fluid  for  diagnostic  purposes,  there  is  no  necessity  to  go  above  the 
third  interspace.  This  is  also  the  usual  space  selected  for  lumbar 
anesthesia. 

The  technique  then  is  as  follows :  The  patient  sits,  or  lies  upon 
his  side,  with  the  lumbar  spine  w^ell  flexed,  in  order  to  separate 
the  spinous  processes.     The  third  interspace  is  determined  by  a 


LUMBAR   PUNCTURE 


583 


palpation.  The  skin  is  anesthetized  by  ethyl  chlorid,  or  the  in- 
jection of  two  or  three  drops  of  a  solution  of  cocain.  It  is  then 
punctured  with  a  narrow,  sharp-pointed  scalpel,  one-half  inch  be- 
low and  one-half  inch  to  the  right  or  left  side  of  the  spinous  proc- 
ess of  the  third  lumbar  vertebra.  This  is  about  on  a  level  with 
the  crest  of  the  ileum  (Fig.  310).  A  small  trocar  and  cannula 
or  a  not  too  sharp  aspirating  needle  is  then  inserted  in  a  direction 
slightly  inward  and  upward  for  a  distance  of  one  and  a  half  to 
two  inches.  It  will  either  enter  the  spinal  canal  or  strike  bone. 
If  it  enters  the  spinal  canal,  serum  will  drop  out  of  the  cannula  or 
needle.  Only  so  much  should  be  allowed  to  escape  as  is  necessary 
for  diagnostic  purposes,  or  as  will  equal  the  bulk  of  the  anesthetic 
to  be  injected.      If  cocain  is  employed,  it  may  be  sterilized  by 


Fig.  310. — The  Bones  of  the  Lumbar  Spine  as  Seen  from  Behind.  The  barrel 
of  syringe  as  here  represented  is  too  far  to  the  right,  giving  the  needle  too  great 
an  inclination.     Compare  Figures  308  and  309. 


dissolving  it  in  ether,  evaporating  to  dryness  in  a  small  glass  dish, 
and  adding  sufficient  water  to  make  a  two  per  cent  solution.  Ten 
minims  of  this  (one-fifth  of  a  grain)  are  usually  sufficient.  It  is 
well  to  know  how  much  fluid  is  required  to  fill  the  needle,  and  to 
make  an  allowance  for  this  in  estimating  the  amount  injected.  It 
takes  ten  minutes  to  produce  a  satisfactory  anesthesia,  and  the 


584  OPERATIVE  TECHNIQUE 

maximum  effect  is  not  produced  until  twice  or  thrice  this  period 
has  elapsed.  The  cannula  may  be  left  in  place  until  it  is  evident 
that  the  anesthesia  will  be  satisfactory.  Care  should  be  taken 
that  no  fluid  escapes  from  it  during  this  waiting  period.  If  neces- 
sary, the  dose  may  bo  repeated  in  ten  or  fifteen  minutes,  and  the 
cannula  removed.  The  wound  in  the  skin  is  covered  with  a  bit 
of  cotton  and  collodion. 

Stovain  (one  per  cent  solution)  is  by  some  preferred  to  cocain. 
The  dose  required  is  about  the  same. 

Transfusion. — -This  term,  which  was  originally  applied  to 
the  transfer  of  blood  from  an  animal  or  man  to  another  man, 
is  now  often  employed  to  denote  the  intravenous  injection  of  a 
normal  saline  solution.  Such  a  solution  may  be  quickly  prepared 
by  adding  a  dram  of  salt  to  the  pint  of  boiled  water,  which  should 
have  a  temperature  of  about  100°  F.  as  it  enters  the  body.  Hence 
it  should  be  somewhat  warmer  than  this  when  placed  in  the  irri- 
gator or  fountain  syringe.  Four  feet  of  rubber  tubing,  termina- 
ting in  a  fine-pointed  glass  nozzle  or  a  blunt-pointed  hollow  needle, 
are  the  other  essentials  of  the  apparatus. 

The  vein  usually  chosen  for  the  injection  is  the  median  cephalic 
vein  which,  crosses  the  anterior  surface  of  the  elbow  obliquely 
from  within  outward  and  upward.  A  light  ligature  around  the 
middle  of  the  upper  arm  will  make  it  more  prominent.  There 
is,  however,  no  necessity  of  selecting  this  vein  if  another  is  more 
readily  found.  In  the  condition  of  acute  anemia,  which  usually 
exists  when  intravenous  injection  is  performed,  "the  veins  are  col- 
lapsed and  are  sometimes  found  with  difficulty.  Under  such  cir- 
cumstances the  position  of  the  vein  in  the  operator's  own  arm  may 
prove  a  guide  to  the  median  cephalic  in  the  arm  of  the  patient. 

The  skin  is  cleansed  by  wiping  it  with  absorbent  cotton  wet 
with  alcohol.  A  transverse  incision  is  made  over  the  vein  which 
has  been  chosen,  dividing  the  skin  only.  The  exposed  vein  is 
seized  with  dissecting  forceps,  and  the  connective  tissue  is  peeled 
from  it  for  a  little  distance  upward  and  downward.  Two  catgut 
ligatures  are  then  passed  around  it,  but  not  tied.  Tension  upon 
these  makes  the  vein  more  prominent,  so  that  it  is  more  easily 
opened.  A  longitudinal  incision  is  then  made  and  the  point  of 
the  metal  needle  or  the  glass  nozzle  is  inserted  in  the  vein  in  the 
direction  of  the  shoulder.     The  upper  ligature  is  tied  in  a  single 


BLOOD-LETTING,   OR  VENESECTION  585 

knot,  thus  compressing  the  vein  around  the  nozzle  and  preventing 
the  entrance  of  air  and  the  escape  of  the  saline  solution.  The 
lower  ligature  is  tied  in  a  square  knot  to  prevent  hemorrhage. 

The  saline  solution  is  injected  slowly,  say  at  the  rate  of  a 
pint  in  five  minutes.  The  rate  and  character  of  the  pulse  are  the 
guides  to  the  amount  which  should  be  employed.  The  injection 
should  be  kept  up  until  there  is  a  distinct  improvement  in  both 
the  rate  and  quality  of  the  pulse.  If  the  hemorrhage  has  been 
severe,  it  is  usually  well  to  inject  at  least  three  pints.  When  the 
injection  is  finished,  the  tube  is  withdrawn,  the  upper  ligature 
tied,  both  ligatures  cut  short,  and  the  skin  sutured. 

If  it  is  necessary  to  repeat  the  injection,  the  same  vein  may 
be  utilized.  The  wound  is  reopened,  the  upper  ligature  cut,  and 
the  nozzle  again  inserted,  and  a  new  ligature  applied  as  before. 

In  conditions  requiring  transfusion  the  veins  are  collapsed, 
else  one  might  use  the  simpler  technique  described  on  page  773. 

Subcutaneous  Infusion. — It  has  been  found  that  saline 
solution,  injected  subcutaneously,  acts  almost  as  promptly  as  when 
it  is  injected  into  a  vein.  The  same  apparatus  is  required,  except- 
ing that  the  hollow  needle  in  which  the  tube  terminates  should 
have  a  sharp  point.  This  is  thrust  into  the  loose  tissues  beneath 
the  breast,  or  around  the  scapula,  or  in  the  loin  or  buttock.  The 
difficulty  is  to  make  the  fluid  flow  fast  enough.  It  is,  therefore,  a 
good  plan  to  connect  the  tube  with  two  needles  by  means  of  a 
glass  Y,  and  to  hasten  the  absorption  by  massage  in  the  vicinity 
of  the  injection.  After  half  an  hour  the  needle  should  be  shifted 
to  another  situation. 

Blood-letting,  or  Venesection. — The  withdrawal  of  blood 
through  an  opening  made  in  one  of  the  larger  veins  is  a  practise 
of  great  antiquity.  At  times  it  has  been  extremely  popular,  and 
at  times  it  has  fallen  into  disuse.  It  is  not  necessary  in  this  place 
to  discuss  the  theory  of  venesection,  or  blood-letting,  but  simply 
to  describe  a  simple  aseptic  technique  for  the  proper  performance 
of  this  little  operation  if  it  should  be  considered  necessary.  The 
vein  usually  chosen  is  the  median  cephalic  vein,  which  crosses  the 
anterior  surface  of  the  elbow- joint  obliquely  from  within  outward 
and  upward,  and  is  made  prominent  by  a  light  ligature  around 
the  middle  of  the  upper  arm.  There  is,  however,  no  necessity  of 
choosing  this  vein,  and  in  some  cases  it  is  not  the  most  prominent 


5SG  OPERATIVE   TECHNIQUE 

one  in  this  vicinity.  Any  well-marked  vein  of  good  caliber  will 
suffice. 

The  skin  should  be  carefully  cleansed  and  strict  asepsis  ob- 
served during  the  operation. 

The  vein  is  exposed  and  opened  by  a  short  incision  from  above 
downward.  This  should  divide  the  skin  and  the  superficial  wall 
of  the  vein. '  If  one  fixes  the  vessel  by  pressure  with  the  thumb, 
a  single  stroke  of  the  point  of  the  knife  will  suffice  to  open  the 
vein.  The  blood  is  allowed  to  escape  into  a  measuring  glass. 
From  one  to  three  pints  should  be  removed,  according  to  circum- 
stances.    It  is  useless  to  withdraw  merely  a  few  ounces. 

"When  sufficient  blood  has  been  withdrawn  the  ligature  is  re- 
moved from  the  upper  arm  and  the  flow  of  blood  is  stopped  by  a 
sterile  gauze  compress  and  bandage.  Or  a  single  suture  may  be 
inserted  to  close  the  wound. 

Cupping. — This  is  a  means  of  drawing  a  small  quantity  of 
blood  to  the  surface  of  the  body  or  of  withdrawing  it  from  the 
body  altogether.  The  former  method  is  spoken  of  as  dry-cupping 
and  the  latter  as  wet-cupping. 

To  obtain  the  best  results  from  dry-cupping  one  should  have 
from  six  to  a  dozen  small  deep  glasses,  an  alcohol  lamp  or  a 
candle,  a  pledget  of  cotton  wound  around  the  end  of  a  stick,  and 
a  small  quantity  of  alcohol  in  a  cup  or  other  convenient  vessel. 

The  surface  of  the  body  where  the  cups  are  to  be  applied  is 
exposed,  the  cotton  swab  is  wet  with  alcohol,  lighted  in  the  candle 
flame,  and  quickly  passed  to  the  bottom  of  an  inverted  cupping- 
glass.  This  heats  the  glass  and  the  air  which  is  contained  in  it. 
The  flame  is  then  withdrawn  from  the  glass,  and  the  latter  is 
quickly  placed,  while  still  inverted,  upon  the  patient's  skin.  As 
the  heated  and  rarefied  air  contained  in  the  glass  cools,  a  partial 
vacuum  is  formed  which  sucks  up  the  underlying  skin  and  causes 
the  blood  to  accumulate  in  it  and  the  sweat  to  exude  from  its 
pores.  The  maximum  effect  is  produced  in  a  minute  or  two. 
Meantime  several  other  cups  will  have  been  burned  out  and  ap- 
plied to  the  adjoining  surface.  The  glasses  used  should  be  thin, 
so  that  they  will  cool  quickly  if  heated.  Two  ounce  whisky 
glasses,  or  the  deeper  glasses  which  hold  three  or  four  ounces,  and 
are  often  used  for  mineral  waters,  answer  the  purpose  admirably. 

Wet-cupping  is  performed  in  the  same  manner  as  dry-cup- 


VACCINATION  587 

ping,  excepting  that  the  skin  is  first  prepared  by  a  number  of 
shallow  incisions.  These  may  be  made  with  a  scalpel  or  with  a 
special  scarificator.  When  the  cup  is  applied  a  dram  or  more  of 
blood  is  withdrawn. 

Leeching. — The  use  of  leeches  to  withdraw  blood  from  a 
bruised  or  inflamed  area  is  still  employed  to  a  certain  extent  in 
spite  of  the  fact  that  infection  may  be  produced  in  this  manner. 
To  reduce  this  risk  the  skin  where  the  leech  is  to  be  applied  should 
first  be  cleansed.  The  leeches  should  be  removed  from  the  water 
in  which  they  are  kept  an  hour  or  more  before  they  are  needed. 
They  will  then  attach  themselves  more  readily.  It  is  well  to  have 
three  or  four  leeches  at  hand,  because  sometimes  one  will  fail  to 
attach  itself,  and  at  the  most  a  single  leech  can  withdraw  only 
two  or  three  drams  of  blood.  If  warm  moist  compresses  are 
kept  over  the  part  after  the  leech  has  dropped  off,  a  little  more 
blood  will  escape. 

Vaccination. — This  little  operation  is  often  performed  with 
the  gravest  disregard  of  surgical  principles.  The  septic  infection 
which  not  infrequently  results  is  the  cause  of  much  of  the  popular 
prejudice  against  vaccination  itself. 

Now  that  vaccine  material  is  supplied  in  surgically  clean  form 
direct  from  the  calf,  there  is  no  opportunity  for  the  doctor  to 
shift  the  responsibility  for  any  bad  result. 

The  skin  of  the  arm  or  leg  of  the  patient  should  be  cleansed 
by  soap  and  water  and  alcohol  or  ether  and  allowed  to  dry.  It 
should  then  be  scratched  over  a  minute  area — not  more  than  one- 
eighth  inch  in  diameter — or  a  very  shallow  incision  may  be  em- 
ployed, the  instrument,  needle  or  scalpel,  having  been  sterilized 
in  a  flame  or  wiped  clean  with  a  cotton  swab  wet  with  alcohol 
or  ether.  The  vaccine  should  be  rubbed  in  with  the  same  sterile 
instrument — not  with  a  match  or  toothpick. 

The  wound  should  be  covered  with  a  large  shield  and  this  with 
a  thin  layer  of  sterile  cotton  and  a  gauze  bandage.  The  part 
should  be  inspected  at  least  every  three  days  and  redressed  as 
often  as  any  serous  discharge  stains  the  dressing.  This  plan  of 
treatment  should  be  continued  until  the  wound  is  entirely  healed, 
and  its  importance  should  be  impressed  upon  the  patient  and  the 
parent. 

For  the  treatment  of  ulcer  following  vaccination  see  page  432. 


CHAPTEK    XXI 
THE   ROLLER   BANDAGE 

GENERAL   PRINCIPLES 

Preparation  of  a  Bandage. — A  roller  bandage  is  a  strip  of 
muslin,  or  other  flexible  material,  which  is  closely  wound  upon 
itself  from  one  end  until  it  forms  a  roll.  This  may  be  done  either 
with  the  fingers  or  with  a  machine  called  a  bandage  roller.  In 
rolling  a  bandage  by  hand  one  should  be  careful  to  make  the  first 
portion  rolled  very  firm,  as  otherwise  it  will  be  impossible  to  make 
the  whole  roll  tight,  and  one  cannot  apply  with  satisfaction  a 
bandage  which  has  been  loosely  rolled. 

To  roll  a  bandage  by  hand  take  eight  inches  of  one  end  and 
fold  it  over  upon  itself.  Do  this  the  second  and  the  third  time. 
There  will  result  a  little  mass  of  bandage  about  one  inch  in  length. 
Seize  the  free  edge  of  this  and  roll  it  tightly  in  upon  itself  until  it 
becomes  encircled  by  the  single  thickness  of  the  bandage.  Con- 
tinue in  this  manner  with  the  thumb  and  finger-tips  until  a  hard 
roll  of  at  least  one-half  inch  in  diameter  is  formed.  This  is  then 
transferred  to  the  left  hand  and  held  between  the  thumb  and  first 
and  second  fingers,  very  much  as  a  bobbin  is  held  on  the  sewing- 
machine.  The  loose  portion  of  the  bandage  is  passed  out  between 
the  thumb  and  first  finger  of  the  right  hand.  By  rocking  motions 
of  both  hands  the  roll  is  turned  away  from  the  loose  bandage  and 
the  latter  is  carried  farther  around  the  roll.  In  this  way  a  very 
presentable  bandage  can  be  rolled  in  a  few  minutes. 

The  bandage  can  be  rolled  more  tightly  and  more  quickly  on 
a  machine  such  as  is  shown  in  Figure  311.  One  end  of  the 
bandage  is  wrapped  around  the  four-sided  bar  of  the  roller  until 
it  is  caught.  One  hand  then  turns  the  roller  while  the  other  keeps 
the  bandage  smooth  and  taut.  When  the  roll  is  finished,  it  is 
grasped  firmly  and  the  bar  of  the  machine  is  turned  a  short  dis- 
tance in  the  reverse  direction.  This  loosens  the  hold  of  the 
588 


PREPARATION   OF   A   BANDAGE  589 

bandage  on  the  bar,  so  that  the  bar  can  be  withdrawn  from 
the  bandage. 

The  materials  ordinarily  employed  for  a  roller  bandage  arc 
gauze,  muslin,  flannel,  canton  flannel,  silk,  stockinette,  rubber,  and 
crinoline.     Each  material  has  its  special  use  (see  Chapter  XXII). 

Every  roller  bandage  has  two  ends.  The  end  which  is  free 
when  a  bandage  is  rolled  up  is  called  the  initial  extremity;  the 


Fig.  311. — Rolling  a  Bandage  on  a  Small  Machine. 

other  end,  which  is  in  the  center  of  the  bandage  as  it  is  rolled  up, 
and  is  therefore  the  last  part  to  be  applied,  is  called  the  terminal 
extremity.  The  two  surfaces  of  the  bandage  are  spoken  of  as 
external  and  internal.  The  external  surface  is  the  only  one 
which  appears  when  the  bandage  is  completely  rolled  up. 

If  a  bandage  is  rolled  up  from  both  ends,  or  if  the  initial  ex- 
tremities of  two  bandages   are  pinned  together,  the  bandage  is 


590  THE   ROLLER    BANDAGE 

called  a  double  roller.  For  the  uses  of  this  bandage  see  Nos.  5 
and  8. 

Application  of  a  Bandage. — In  applying  a  roller  band- 
age, the  external  surface  should  always  be  placed  in  contact  with 
the  skin.  As  the  bandage  is  then  applied,  it  will  roll  away  from 
the  limb,  and  constantly  unwind  itself;  whereas,  if  the  inner  sur- 
face is  applied  to  the  patient,  the  bandage  does  not  unroll  readily, 
and  is  likely  to  be  pulled  out  of  the  hand  of  the  bandager.  Of 
course  when  reverses  are  made,  each  one  changes  the  surface  of 
the  bandage  which  is  directed  toward  the  patient,  so  that  the  ex- 
ternal surface  of  the  bandage  cannot  always  be  directed  toward 
the  limb. 

Anchoring1. — The  bandage  having  been  correctly  placed,  the 
next  step  is  to  fix  or  anchor  it.  The  bandager  with  one  finger 
or  thumb,  or  with  both  digits,  holds  the  initial  extremity  of  the 
bandage  firmly  against  the  part  around  which  the  bandage  is  to 
be  anchored.  The  other  hand  carries  the  bandage  around  such 
part  and  back  to  the  starting-point.  As  soon  as  the  bandage  has 
completed  a  little  more  than  the  circle,  its  own  pressure  will 
keep  it  from  slipping,  and  the  first  hand  lets  go  its  hold.  The 
bandage  is  now  continued  spirally,  being  passed  from  hand  to 
hand  as  it  is  carried  around  the  limb.  Every  person  should 
practise  bandaging  until  he  can  bandage  easily  from  right  to 
left,  or  left  to  right,  and  cause  the  bandage  to  progress  toward 
him  or  away  from  him,  according  to  circumstances. 

Spiral  Reverse. — In  applying  a  spiral  bandage  from  the  apex 
to  the  base  of  a  cone,  the  edge  of  the  bandage  nearer  the  apex 
constantly  travels  through  a  smaller  spiral  than  the  edge  of  the 
bandage  nearer  the  base.  If  the  bandage  is  inelastic,  the  edge 
nearer  the  apex  will  always  be  loose.  The  limbs  of  the  body,  when 
a  person  stands  erect,  are  inverted  cones ;  hence  the  lower  edge 
of  a  bandage  applied  to  them  will  always  be  loose.  In  stout  per- 
sons this  is  more  marked  than  in  slender  ones.  One  should  never 
attempt  to  overcome  it  by  a  hard  pull  upon  the  bandage.  This 
will  cause  an  undue  pressure  upon  the  upper  edge  of  the  band- 
age, which  will  be  pressed  into  the  flesh  and  will  cause  a  spiral 
groove  in  the  flesh.  This  fulness  of  the  lower  edge  of  the  band- 
age is  to  be  overcome  by  reversing  the  bandage,  or  by  changing 
its  direction,  so  that  a  figure  of  eight  is  formed. 


APPLICATION   OF   A   BANDAGE  .591 

To  make  a  reverse  in  a  spiral  bandage,  the  bandager  should 
first  select  a  longitudinal  line  upon  which  the  reverses  are  to 
be  made.  For  the  sake  of  appearance,  this  is  usually  the  center 
of  the  anterior  or  posterior  surface  of  the  limb.  When  the  lower 
edge  of  the  bandage  becomes  full,  its  direction  should  be  changed, 


Fig.  312. — Making  a  Reverse  in  a  Spiral  Bandage.  The  left  hand  holds  the  band- 
age, while  the  right  reverses  it.  The  angle  made  should  be  such  that  the  ascend- 
ing and  descending  portions  correspond  in  direction. 

until  both  edges  lie  equally  smooth.  While  the  right  hand  holds 
the  bandage  taut,  the  left  thumb  or  forefinger  is  placed  on  the 
lower  edge  of  the  bandage,  about  an  inch  beyond  the  median  line 
of  the  limb.  The  right  hand  slacks  up  the  bandage  beyond  this 
point,  and  turns  it  smoothly  on  itself  at  such  an  angle  that  it 
will  now  descend  the  limb  as  rapidly  as  it  ascended  it  before  (Fig. 
312).  When  this  is  accomplished,  the  right  hand  again  pulls  the 
bandage  taut,  and  the  left  hand  is  removed. 

Each  time  the  bandage  passes  the  median  line  of  the  limb,  the 
bandage  is  again  reversed,  until  the  conical  portion  of  the  limb 
has  been  covered. 

Overlapping  of  the  Turns. — The  distance  between  the  turns  of 
bandage  in  a  simple  spiral  or  a  spiral  reverse  should  be  equal  to 
one-half  or  one-third  of  the  width  of  the  bandage.     It  is  obvious 


592 


THE   ROLLER    BANDAGE 


that  if  the  progress  of  each  turn  is  just  one-half  the  width  of  the 
bandage  there  will  be  a  double  layer  of  bandage  over  the  whole 
surface,  and  four  thicknesses  of  bandage  in  the  reverses  and  points 
of  crossing.  If  the  progress  of  each  turn  is  only  one-third  of  the 
width  of  the  bandage,  there  will  be  three  thicknesses  of  bandage 
over  the  whole  area  covered,  and  six  thicknesses  in  the  reverses 
and  pi  lints  of  crossing.  The  portion  of  the  bandage  where  the 
reverses  are  made  is  the  firmest  part,  and  the  part  where  the 
greatest  amount  of  pressure  is  exerted.  If,  therefore,  a  reverse 
or  a  figure  of  eight  bandage  is  applied  in  order  to  make  pressure 
upon  a  wound,  it  is  often  desirable  to  bring  the  reverses  directly 
over  the  wounded  part,  even  at  the  sacrifice  of  appearance. 

Figure  of  Eight. — The  second  method  of  taking  up  the  slack 
or  fulness  in  the  lower  edge  of  a  spiral  bandage  is  known  as  a 


Fig.  313.- 


-Making  a  Figure  of  Eight  Turn  Above  the  Greatest  Circumfer- 
ence of  the  Forearm. 


figure   of  eight.      The   direction  of  the  bandage  is  altered  until 
both  edges  fit  the  surface  equally.     This  means  that  the  bandage 


APPLICATION  OF  A  BANDAGE  593 

is  carried  sharply  upward.  It  is  then  carried  around  the  limb, 
and  brought  sharply  downward,  crossing  the  upward  turn  at  a 
point  a  half  an  inch  or  more  beyond  the  median  line  of  the  limb 
(Fig.  313). 

If  the  part  of  the  limb  utilized  for  this  figure  of  eight  is  a 
perfect  cone,  the  distances  traveled  by  the  upper  and  lower  edges 
of  the  bandage  are  not  equalized  by  this  maneuver,  since  what  is 
gained  by  carrying  the  bandage  sharply  upward  is  lost  again  by 
bringing  it  sharply  downward.  The  practical  point  is  the  fact 
that  the  fulness  is  all  kept  in  the  upper  horizontal  portion  of  the 
figure  of  eight  where  it  will  be  covered  by  subsequent  turns  of  the 
bandage. 

If  the  figure  of  eight  is  so  placed  that  its  lower  loop  is  around 
an  inverted  cone,  and  its  upper  loop  is  around  an  upright  cone, 
then  there  exists  a  real  equalization  of  the  distances  traveled  by 
the  upper  and  lower  edges  of  the  bandage,  and  a  considerable 
amount  of  fulness  is  disposed  of.  This  happens  in  the  case  of 
the  figure  of  eight  of  the  leg,  provided  it  reaches  above  the  great- 
est circumference  of  the  calf;  in  the  figure  of  eight  of  the  upper 
part  of  the  forearm ;  in  the  figure  of  eight  of  the  swollen  knee,  etc. 

Where  the  figure  of  eight  turn  leaves  the  spiral  there  is  a  thin 
spot  or  even  a  triangular  gap  in  the  bandage.  This  should  be 
covered  in  by  an  additional  spiral  turn  introduced  between  the 
first  and  second  figure  of  eight  turns. 

The  Spica. — The  name  spica  was  originally  suggested  by  the 
resemblance  of  the  crossings  in  a  spiral  reverse,  or  figure  of 
eight  bandage  to  an  ear  of  wheat  or  barley.  It  is  now  generally 
restricted  to  such  figure  of  eight  bandages  as  cover  a  joint  between 
an  extremity  and  the  trunk,  or  between  a  smaller  and  a  larger 
portion  of  an  extremity.  For  instance,  the  spica  of  the  shoulder 
(Fig.  362,  p.  644)  or  the  spica  of  the  thumb  (Fig.  372,  p.  652). 
With  this  restriction,  the  name  serves  a  useful  purpose,  whereas 
if  it  were  applied  indiscriminately  to  every  spiral  reverse  or  figure 
of  eight  bandage,  it  would  have  comparatively  little  value. 

The  Amount  of  Pressure. — The  pressure  exerted  by  a  bandage 
should  be  uniform.  This  is  best  secured  by  applying  the  bandage 
under  slight  constant  tension,  and  by  introducing  a  reverse  or  a 
figure  of  eight  as  soon  as  one  edge  of  the  bandage  is  looser  than 
the  other.     There  is  a  tendency  for  beginners  to  exert  too  much 


594 


THE    ROLLER    BANDAGE 


pressure  upon  ;i  bandage  during  its  application.  As  a  result, 
the  patient  is  made  uncomfortable,  and  the  circulation  is  inter- 
fered with,  so  that  if  the  limb  has  already  been  injured,  areas 
of  necrosis  or  gangrene  may  result.  One  should  always  note  the 
character  of  the  circulation  after  applying  a  bandage  to  an  ex- 
tremity, and  if  the  tip  of  the  extremity  is  cyanotic,  or  the  bandage 
is  painful,  it  should  be  removed  and  reapplied.     This  takes  but 

a  few  minutes,  and 
may  obviate  hours  of 
discomfort,  or  some 
more  serious  compli- 
cation. Whenever  a 
bandage  is  applied  for 
pressure,  it  should 
either  be  an  elastic 
bandage  or  it  should 
be  placed  outside  of  a 
layer  of  elastic  mate- 
rial, such  as  unbleached 
cotton  or  lamb's  wool. 
The  pressure  will  then 
be  diffuse,  and  the  risk 
of  injury  to  the  tissues 
will  be  minimized. 

Completion  of  the 
Bandage. — The  band- 
age is  usually  com- 
pleted by  a  circular 
turn.  The  end  is  then 
stitched  or  pinned  or 
stuck  down  with  a 
short  piece  of  adhesive 
plaster;  or  the  end  of 
the  bandage  is  split, 
and  one-half  of  it  is 
direction,  and  the  two 


Fig.  314.  —  Fastening  a  Bandage  by  Splitting 
the  End  and  Tying  the  Halves  Together 
Around  the  Limb.  The  right  hand  holds  the 
half  of  the  bandage  which  is  to  be  carried  around 
the  limb  in  the  reverse  direction.  Note  that 
this  half  of  the  bandage  crosses  underneath  the 
other  half. 

carried  around  the  limb  in  the  opposite 


ends  are  tied  together  (Fig 


314). 


HORIZONTAL  CIRCULAR   BANDAGE  OF  HEAD 


595 


BANDAGES   OF   THE   HEAD 

Wo.  1.  Horizontal  Circular,  or  Occipitofrontal;  a 
Two  Inch  Bandage. — The  area  covered  by  this  bandage  is  a 
circular  zone  across  the  forehead,  above  both  ears,  and  across  the 
occipital  region.  It  is  of  use  to  control  hemorrhage  from  scalp 
wounds,  and  to  fix  a  dressing  anywhere  in  this .  area. 

The  bandage  is  started  on  the  forehead  or  occipital  region 
and  carried  around  the  head  until  the  occipitofrontal  circle  is 


Fig.  315. — Occipitofrontal,  Bandage  of  the  Head,  Showing  Anchoring. 


completed  (Fig.  315).  This  anchors  the  bandage.  Several  addi- 
tional turns  are  then  made  directly  over  the  first  one  in  front, 
but  slightly  above  and  below  it  behind,  in  order  to  prevent  it 
from  slipping.  If  greater  security  is  desired,  as  in  the  case  of 
an  alcoholic  patient,  the  single  or  double  oblique  circular  (Nos. 
2  and  3)  should  be  added,  and  the  four  intersections  stitched 
or  pinned.  Greater  security  is  also  obtained  by  giving  the  band- 
age a  half  twist  with  every  half  circle  or  every  full  circle.     This 

takes  up  the  slack  at  the  edges  of  the  bandage. 
40 


596 


THE   ROLLER    BANDAdi: 


No.  2.  Oblique  Circular;  a  Two  Inch.  Bandage.— 
The  area  covered  by  this  bandage  is  the  vertex  of  the  skull,  the 
temporal  region  ami  cheek  of  <>nc  shir,  the  under  surface  of  the 
chin,  and  the  mastoid  region  of  the  other  side.  It  is  useful  in 
seal])  wounds,  and  to  hold  a  dressing  in  place  either  in  front  of 
or  behind  the  ear.  It  is  not  so  firm  a  bandage  as  the  double 
oblique  circular  (Xo.  3)  or  the  crossed  circular  (Xo.   1). 

The  bandage  is  started  on  the  vertex  of  the  skull,  and  carried 
behind  one  cur  under  the  chin,  in  fronl  of  the  other  ear,  and  back 


Fig.  316. — Oblique  Circular  Bandage  of  the  Head,  the  First  Turn 

Completed. 


to  the  starting-point  (Fig.  316).     This  anchors  the  bandage.     Sev- 
eral additional  turns  are  made  directly  over  the  first  one. 

No.  3.  Double  Oblique  Circular ;  a  Two  Inch  Band- 
age. — The  area  covered  by  this  bandage  is  the  vertex  of  the  skull, 
the  temporal  and  mastoid  regions  and  cheeks  of  both  sides,  and 
the  under  surface  of  the  chin.  It  is  useful  in  scalp  wounds,  and 
to  hold  a  dressing  in  place  either  in  front  of  or  behind  the  ear. 
It  is  a  firmer  bandage  than  No.  2,  and  may  be  made  to  cover  a 


CROSSED  CIRCULAR    BANDAGE  OF   HEAD 


597 


greater  area  on  the  vertex  of  the  skull,  since  the  succeeding  turns 
may  overlap  a  little  without  slipping. 

The  bandage  is  started  on  the  vertex  of  the  skull,  and  carried 
behind  the  left  ear,  beneath  the  chin,  and  in  front  of  the  right 


Fig.  317. — Double  Oblique  Circular  Bandage  of  the  Head,  Showing  the  Com- 
pletion of  the  Second  Turn. 

ear  to  the  starting-point.  This  anchors  the  bandage.  The  second 
turn  follows  the  first  until  it  reaches  the  chin,  and  then  ascends 
behind  the  right  ear  to  the  starting-point  (Fig.  317).  The  third 
turn  passes  in  front  of  the  left  ear,  under  the  chin,  and  in  front 
of  the  right  ear  to  the  starting-point.  A  repetition  of  these  three 
turns  will  make  a  firmer  bandage,  and,  if  desired,  the  turns  which 
pass  in  front  of  the  ears  may  be  carried  slightly  farther  forward 
without  weakening  the  bandage.  This  increases  the  area  covered 
by  the  bandage  on  the  cheeks,  temporal  regions,  and  vertex  of 
the  skull. 

No.  4.  Crossed  Circular;   a  Two  Inch  Bandage.— The 
area  covered  by  this  bandage  is  that  of  two  intersecting  circles, 


59S 


THE   ROLLER    BANDAGE 


one  horizontal  and  one  vertical.  The  Eoraier  is  the  occipito 
frontal  circle  covered  by  bandage  ISTo.  1.  and  the  latter  is  the 
circle  covered  by  bandage  Xo.  2.  The  bandage  is  chiefly  used  to 
control  hemorrhage  from  the  vertex  of  the  head,  or  to  maintain 
a  dressing  in  position  on  the  top  of  the  head,  in  front  of  the  ear, 
or  at  the  angle  of  the  jaw.  The  occipitofrontal  circle  serves  to 
retain  the  other  in  position. 

The  bandage  is  started  beneath  the  chin  and  carried  upward 
in  front  of  the  ear  on  the  injured  side,  across  the  top  of  the  head, 
and  behind  the  ear  on  the  opposite  side  to  the  starting-point,  This 
anchors  the  bandage.     Subsequent  turns  may  exactly  overlie  the 


Fig.  318. 


-The  Crossed  Circular,  One  of  the  Best  Head  Bandages. 
tration  shows  the  completion  of  the  second  circle. 


The  illus- 


first,  or  may  overlap  it  slightly  in  front  or  behind.  The  end  of 
the  bandage  is  fastened  with  a  pin  or  with  adhesive  plaster.  A 
circular  bandage  is  next  applied  from  the  forehead  to  the  occiput 
(Fig.  318).  When  this  circle  is  completed,  the  intersections  of 
the  two  circles  are  sewed  or  pinned. 

The  horizontal  circular  bandage  can  be  equally  well  combined 
with  the  double  oblique  circular  bandage  (ISTo.  3). 


KNOTTED   BANDAGE  OF  HEAD 


509 


No.  5.  Knotted  Bandage ;  Two  Two  Inch  Bandages, 
or  a  Double  Roller. — The  area  covered  by  this  bandage  is 
composed  of  two  intersecting  circles,  the  occipitofrontal  circle 
and  the  vertical  circle.     It  is  chiefly  used  to  control  hemorrhage  or 


Fig.  319. — Knotted  Bandage  of  the  Head,  Showing  the  First  Intersection. 


make  pressure  in  the  temporal  region.  It  may  be  applied  with 
a  double  roller  or  with  two  single  rollers,  the  initial  extremities 
of  which  are  pinned  or  stitched  together. 

.The.  .center.. of .  the.  double  roller  is  placed  over  the  right  ear, 
and  the  two  ends  are  carried  horizontally,  one  across  the  fore- 
head' anu1  'th^'dther  across  the  occiput,  until  they  meet  in  the 
temporal'- region  ;o'f  the i'le'ft  side.1  They  are  then  crossed,  and  the 
lower  ^roller  is  carried  upward  over  the  vertex  and  the  upper 
'roller ;  'downward-  -uniler-  the  ■-chili  '(iFig.   319).     When  they  meet 


600 


THE   ROLLER    BANDAGE 


in  the  right  temporal  region  they  are  again  crossed,  the  anterior 
roller  being  carried  around  the  occiput,  and  the  posterior  one 
across  the  forehead.  By  repeating  these  turns  several  times, 
firm  pressure  will  be  made  in  each  temporal  region.  Care  should 
be  taken  to  see  that  the  knots  or  intersections  of  the  bandage 
exactly  overlie  each  other. 

No.  6.  Figure  of  Eight  of  Head;  a  Two  Inch  Band- 
age.— The  area  covered  by  this  bandage  is  the  central  portion 
of  the  vertex  of  the  skull,  both  temporal  regions,  both  cheeks, 
and  the  under  surface  of  the  chin,  both  parietal  regions  and 
the  lower  part  of  the  occipital  region.  It  is  a  very  firm  bandage, 
especially  when  combined  with  the  horizontal  circular  (Xo.  1), 
and  is  serviceable  to  control  hemorrhage  or  fix  a  dressing  on  the 
vertex  of  the  skull  where  a  very  firm  pressure  is  easily  made. 


Fig.  320. — Figure  of  Eight  Bandage  of  the  Head,  Showing  Anchoring. 

The  bandage  is  started  on  the  vertex,  about  over  the  coronal 
suture,  and  carried  in  front  of  one  ear,  under  the  chin,  and  in 
front  of  the  other  ear  to  the  starting-point.  It  is  then  carried 
under  the  occiput  and  back  to  the  starting-point.     This  anchors 


SINGLE  ROLLER    BANDAGE  OF  HEAD 


601 


the  bandage,  but  two  or  three  additional  figure  of  eight  turns  are 
necessary  in  order  to  make  it  solid.  The  point  of  intersection  of 
this  bandage  should  be  far  enough  forward  to  keep  the  occipital 
loop  from  slipping  upward.  Succeeding  turns  may  overlap  each 
other  a  little  on  the  vertex,  thus  increasing  the  area  covered  (Fig. 
320). 

No.  7.  Recurrent  or  Single  Roller;  a  Two  Inch 
Bandage. — The  area  covered  by  this  bandage  is  the  whole  scalp, 
but  it  exerts  firm  pressure  only  in  the  occipitofrontal  circle  cov- 


Fig.  321. — Single  Roller  Bandage  of  the  Head.  Beginning  in  the  median  line 
the  surgeon  lays  each  succeeding  turn  of  the  bandage  a  little  farther  to  the  right 
and  left. 

ered  by  bandage  ISTo.  1.  It  is  of  use  to  keep  a  dressing  of  the 
scalp  in  place,  but  it  should  not  be  employed  to  control  hemor- 
rhage from  scalp  wounds  of  the  vertex,  for  which  purpose  bandages 
No.  4  and  ISTo.  6  are  better. 

The  bandage  is  started  on  the  forehead,  and  carried  directly 
over  the  vertex  to  a  point  a  little  below  the  occiput,  reversed  and 
carried  back  to  the  starting-point.  In  making  this  return  the 
bandage  should  overlap  itself  to  the  right  by  one-half  its  width. 


602 


THE   ROLLER   BANDAGE 


It  is  reversed  on  the  forehead,  and  carried  to  the  occiput,  over- 
lapping itself  to  the  left  by  one-half  its  width  (Fig.  321).  These 
forward  and  backward  turns  are  continued,  each  one  a  little 
farther  from  the  median  line  than  the  preceding  one,  until  the 
whole  scalp  is  covered.  Two  circular  turns,  without  reverses, 
are  then  carried  across  the  forehead,  above  both  ears,  and  across 
the  occiput.  These  serve  to  fasten  the  whole  bandage.  As  this 
bandage  is  not  anchored  until  it  is  completed,  it  is  necessary 
that  either  the  patient  or  an  assistant  hold  the  loose  ends  of  the 
reverses  on  the  forehead.  The  surgeon  can  hold  the  loose  ends 
under  the  occiput  until  the  circular  turns  of  the  bandage  fix  them 
in  position.  On  account  of  this  drawback  in  its  application,  the 
double  roller  (Xo.  8)  is  usually  preferred  to  the  single  roller. 

This  bandage  may  be  applied  in  two  ways:  The  reverses  on 
the  forehead   and   occiput  may  all  be  made  in  the  median  line. 


Fig.  322. — Single  Roller  Bandage  of  the  Head  Completed. 

The  various  turns  of  the  bandage  will  then  all  come  to  a  single 
point  in  front,  and  to  a  single  point  behind,  like  the  ribs  of  a 
melon  (Fig.  322).     Another  method  is  to  make  the  forward  and 


DOUBLE   ROLLER   BANDAGE   OF   HEAD  603 

backward  turns  more  nearly  parallel  by  making  each  reverse  on 
the  forehead  and  occiput  a  little  farther  from  the  median  line. 
When  half  of  the  scalp  has  been  covered,  the  bandage  is  carried 
through  the  occipitofrontal  circle,  and  brought  to  the  median  line. 
It  is  there  reversed,  and  by  forward  and  backward  turns  the 
other  half  of  the  scalp  is  covered. 

Another  variation  of  this  bandage  is  to  stop  the  forward  and 
backward  turns  when  only  a  part  of  the  scalp  has  been  covered, 
and  then  to  fix  the  turns  already  made  by  two  circular  turns. 
In  this  manner,  for  instance,  one-half  of  the  vertex  of  the  skull 
can  be  covered  by  the  bandage.  This  variation  is  seldom  em- 
ployed, since  it  is  apt  to  loosen  and  get  out  of  place.  The  double 
roller  (]STo.  8)  is  better  than  the  single  roller  for  this  purpose, 
or  one  may  use  the  oblique  circular  (No.  2)  or  figure  of  eight 
(No.  6). 

No.  8.  Recurrent  or  Double  Roller ;  a  One  and  One- 
Half  Inch  Bandage  and  a  Two  Inch  Bandage. — The  area 
covered -by- this  bandage  and  the  uses  for  which  it  is  applied  are 
the  same  as  those  of  the  single  roller  bandage  (No.  7).  Although 
it  is  somewhat  firmer  than  the  latter,  it  should  not  be  used  to 
control  hemorrhage  on  the  vertex.  It  has  a  distinct  advantage 
over  the  single  roller  in  that  it  can  be  applied  by  one  person 
without  assistance. 

The  one  and  one-half  inch  bandage  is  started  on  the  forehead 
and  carried  horizontally  around  the  head.  This  anchors  the 
bandage.  A  second  turn  is  made  directly  over  the  first,  but  just 
before  the  bandage  reaches  the  starting-point  the  end  of  the  two 
inch  bandage  is  laid  beneath  it,  so  that  it  may  be  anchored  by 
the  circular  turn  of  the  narrower  bandage.  Without  changing 
hands,  the  operator  carries  the  wider  bandage  across  the  vertex 
of  the  skull  and  down  the  neck,  and  carries  the  circular  bandage 
over  it  at  the  occiput.  It  is  now  necessary  to  change  each  band- 
age to  the  other  hand.  The  wider  bandage  is  then  carried  to 
the  forehead,  slightly  to  the  left  of  the  median  line,  where  it 
is  again  crossed  by  the  circular  bandage,  and  is  then  carried  back 
to  the  occiput,  slightly  to  the  right  of  the  median  line.  Bandages 
are  again  changed  each  to  the  other  hand,  and  the  wider  bandage 
is  again  brought  to  ,  the  forehead,  and  crossed  by  the  narrower 
one  (Fig.  323).     These  forward  and  backward  and  circular  turns 


Fig.  323. — Double  Roller  Bandage  of  the  Head.  Each  circular  turn  of  the  nar- 
rower bandage  fixes  the  reverse  of  the  wider  one  on  the  forehead  and  on  the  occi- 
put. 


Fig.  324. — Double  Roller  Bandage  Completed. 
604 


PARTIAL  RECURRENT  BANDAGE  OF  HEAD 


005 


are  continued  until  the  head  is  covered.  One  of  the  bandages 
is  then  cut  off  and  an  additional  circular  turn  of  the  other 
bandage  (the  wider  one  in  the  case  photographed)  fixes  the  whole 
in  position.  The  end  of  this  bandage  is  fastened  with  adhesive 
plaster  or  a  safety  pin  (Fig.  324). 

The  disadvantage  of  this  bandage  consists  in  the  thick  band 
which  is  formed  around  the  head  by  so  many  circular  turns.  It 
is  to  lessen  this,  and  also  to  make  it  fit  a  little  better,  that  the 
narrower  bandage  is  chosen.  The  chief  advantage  of  the  bandage 
is  the  avoidance  of  turns  beneath  the  chin.  These  are  conspicu- 
ous and  often  uncomfortable,  so  that  patients  frequently  object 
to  them. 

No.  9.  Partial  Recurrent ;  a  Modification  of  the 
Double  Roller ;  Two  One  and  One-Half  Inch  Bandages. 
- — The  area  covered  by  this  bandage  is  the  horizontal  circle  from 


Fig.  325. — Partial,  Recurrent  Bandage  of  the  Head,  Showing  how  the  Trans- 
verse Turns  are  Anchored  by  the  Circular  Turns.  Note  the  disposition 
of  the  hair. 


the  forehead  to  the  occiput,  and  any  desired  portion  of  the  vertex. 
Its  use  is  to  keep  a  small  dressing  on  the  vertex  without  covering 


606 


i  in;  roller   uandaoe 


any  portion  of  the  face  or  neck,  while  permitting  the  patient  to 
comb  at  least  a  portion  of  the  hair. 

One  bandage  is  anchored  by  carrying  it  horizontally  around 
the  head.  The  other  bandage  is  caught  in  the  circular  turns 
at  the  side  of  the  head,  and  is  carried  hack  and  forth  trans- 
versely three  or  four  times  (Fig.  325).  This  gives  a  fairly  firm 
bandage.  It  is  especially  serviceable  in  the  case  of  a  woman 
whose  long  hair  can  he  parted  transversely  at  the  site  of  the 
wound,  and  brought  out  in  two  portions,  one  in  front  of  and  one 
behind  the  transverse  part  of  the  bandage. 

No.  10.  Figure  of  Eight  of  One  Eye;  a  One  and 
One-half  Inch  Bandage.- — The  area  covered  is  the  horizontal 
occipitofrontal  circle,  and  one  eye,  with  a  portion  of  the  adjoining 


Fig.  326. — Figure  of  Eight  Bandage  of  One  Eye. 


cheek.     The  use  of  this  bandage  is  to  keep  a  dressing  in  place 
over  the  eye,  or  to  protect  the  eye  from  light,  etc. 

In  order  to  bandage  the  right  eye  the  bandage  is  started  on 
the  forehead,  and  carried  over  the  left  ear,  across  the  occiput, 
over- the  right  ear,,  and  to'  the -starting-point.     This  anchors  the 


FIGURE   OF   EIGHT   BANDAGE  OF   BOTH   EYES  607 

bandage.  It  is  then  carried  over  the  left  ear,  across  the  occiput, 
under  the  right  ear,  across  the  right  cheek,  and  over  the  right  eye 
close  to  the  nose  (Fig.  320).  The  second  horizontal  circular 
turn  is  then  made  directly  over  the  first,  and  a  second  oblique 
turn  is  made  directly  over  the  first  oblique  turn,  until  the  cheek 
is  reached.  Here  the  bandage  should  be  carried  slightly  above 
the  first  turn,  so  that  on  passing  the  eye  the  second  turn  progresses 
beyond  the  first  by  one-third  of  its  width.  This  may  complete 
the  bandage,  but  usually  a  third  circular  turn  and  a  third  oblique 
turn  are  desirable.  To  avoid  making  pressure  upon  the  eye,  the 
oblique  turns  of  this  bandage  should  not  be  drawn  tightly.  The 
patient  is  usually  more  comfortable  if  the  oblique  turns  are  not 
all  carried  below  the  ear.  It  is  sometimes  a  good  plan  to  place  a 
thin  fold  of  gauze  or  cotton  behind  the  ear  and  then  to  allow  the 
oblique  turns  to  pass  across  the  ear  instead  of  below  it. 

No.  11.  Figure  of  Eight  of  Both  Eyes;  a  One  and 
One -half  Inch  Bandage. — The  area  covered  by  this  bandage 
is  the  occipitofrontal  circle,  both  eyes,  and  a  part  of  both  cheeks. 
The  use  of  this  bandage  is  to  keep  dressings  in  place  over  both 
eyes  or  to  protect  both  eyes  from  the  light,  etc. 

In  bandaging  one  eye  the  oblique  turns  pass  from  the  cheek 
to  the  eye^  each  one  a  little  higher  than  the  preceding  one,  as  this 
gives  a  better  fitting  bandage.  In  bandaging  both  eyes,  it  is  im- 
possible to  do  this  on  both  sides  of  the  face.  The  bandage  should 
therefore  encircle  the  head  in  such  a  manner  that  the  oblique 
turns  will  ascend  over  the  more  seriously  injured  eye.  Suppose 
this  to  be  the  right  eye.  The  bandage  is  started  on  the  forehead, 
and  carried  above  the  left  ear  across  the  occiput,  over  the  right 
ear,  and  to  the  starting-point.  This  anchors  the  bandage.  It  is 
then  carried  over  the  left  ear,  across  the  occiput,  beneath  the  right 
ear,  across  the  right  cheek  and  eye  as  low  down  as  it  is  desired 
that  the  bandage  should  extend,  and  back  to  the  starting-point. 
It  is  next  carried  above  the  left  ear,  across  the  occiput,  above  the 
right  ear,  back  to  the  starting-point,  and  across  the  left  eye  and 
cheek  as  low  down  as  it  is  desired  that  the  bandage  should  extend. 
The  succeeding  oblique  turns  should  be  placed  a  little  higher  than 
the  first  ones.  In  this  manner  the  bandage  is  continued  until 
both  eyes  have  been  covered.  A  variation  consists  in  placing  a 
thin  pad  behind  each  ear,  and  carrying  the  oblique  turns  directly 


60S 


llli:    KOI.I.KK     UANDAliK 


across  the  ear-.  Instead  of  below  them  (Fig.  327).  This  variation 
was  followed  in  the  bandage  shown  in  the  accompanying  illus- 
tration. 


Fig.  327. — Figure  of  Eight  Bandage  of  Both  Eyes.     The  bandage  has  been  an- 
chored, and  the  second  oblique  turns  over  each  eye  have  been  applied. 

No.  12.  Four-tailed  Bandage  ;  a  Three  Inch  Bandage, 
Thirty-six  Inches  Long. — This  bandage  is  employed  to  make 
pressure  upward  and  backward  upon  the  point  of  the  chin.  It  is 
therefore  useful  in  fracture  of  the  lower  jaw.  A  strip  of  muslin 
a  yard  long  and  three  inches  wide  is  split  up  from  each  end  to 
within  five  inches  of  the  center.  The  four  ends  thus  made  are 
called  "  tails."  In  the  center  of  the  bandage  a  longitudinal  slit 
is  made,  or  an  elliptical  piece,  two  inches  in  length,  is  cut  out 
(Fig.  8,  p.  21).  The  opening  is  placed  over  the  point  of  the  chin; 
one-half  of  the  bandage  will  then  rest  beneath  the  chin  and  the 
other  half  upon  its  anterior  surface.  Those  two  ends,  or  "  tails," 
of  the  bandage,  which  are  a  continuation  of  the  half  of  the  band- 
age which  is  in  front  of  the  chin,  are  carried  backward  beneath  the 
ears,  and  tied  together  in  a  square  knot  at  the  occiput.  The  other 
two  "  tails  "  of  the  bandage  are  carried  upward  across  the  cheeks, 


BARTON'S    BANDAGE 


600 


and  tied  together  in  front  of  the  coronal  suture.  The  four  ends 
which  have  been  left  long  for  the  purpose  are  then  tied  together 
on  the  vertex,  one  pair  to  the  right  of  the  median  line  and  the 
other  pair  to  the  left  of  the  median  line.  In  tying  these  knots 
sufficient  strain  should  he  put  upon  the  bandage  to  draw  the  chin 
upward  and  backward. 

A  simpler  plan,  though  possibly  a  little  less  comfortable  to  the 
patient,  is  to  tie  the  pairs  of  "  tails  "  together  in  the  median  line 


Fig.  328.— The  Four-tailed  Baxdage.     Tying  the  final  knot  exerts  pressure  upon 
the  chin,  both  upward  and  backward. 

(Fig.  328),  or  to  cut  off  one  "tail"  after  the  frontal  knot  has 
been  tied,  and  one  "  tail "  after  the  occipital  knot  has  been  tied, 
and  to  tie  the  two  remaining  "  tails  "  in  the  median  line. 

~No.  13.  Barton's  ;  a  Two  Inch  Bandage. — The  area  cov- 
ered by  this  bandage  is  the  central  portion  of  the  vertex  of  the 
skull,  both  temporal  regions,  both  cheeks,  the  under  surface  of 
the  chin,  the  front  of  the  chin,  both  parietal  regions,  the  lower 
part  of  the  occipital  region,  and  the  sides  of  the  neck.     Its  use  is 


010 


THE    ROLLER    BANDAGE 


not;  however,  to  control  a  hemorrhage  or  maintain  a  dressing 
in  any  of  these  situations,  but  to  exert  pressure  upon  the  chin, 
both  upward  and  backward.  It  is  applied  in  ease  of  fra'cture 
of  the  lower  jaw.  It  is  a  combination  of  the  figure  of  eight  of 
the  head  (No.  G)  and  a  horizontal  turn  around  the  chin  and 
neck. 

The  bandage  is  started  on  the  vertex  at  or  in  front  of  the 
coronal  suture,  and  carried  downward  behind  the  left  ear,  across 
i he  hack  of  the  neck,  forward  beneath  the  right  ear,  across  the 
chin,  and  horizontally  backward  to  the  occiput.  It  is  then  carried 
upward  behind  the  right  ear  to  the  starting-point,  From  there 
it  is  carried  downward  in  front  of  the  left  ear,  across  (he  cheek, 
under  the  chin,  and  upward  in  front  of  the  right  ear  to  the  start- 
ing-poinl  (  Fig.  329).     The  bandage  is  then  carried  over  the  exist- 


Fig.  329. — Barton's  Bandage,  with  First  Layer  Completed. 
resented  as  just  starting  on  the  second  layer. 


The  roller  is  rep- 


ing  turns  twice  or  three  times,  to  give  it  added  security.  Inter- 
sections of  the  bandage  may  be  stitched  or  pinned.  This  bandage 
is  more  complicated  than  the  four-tailed  bandage,  and  presents  no 
points  of  advantage. 


GIBSON'S    BANDAGE 


611 


No.  14.  Gibson's;  a  Two  Inch  Bandage. — This  is  a 
bandage  composed  of  three  circles — a  circle  from  beneath  the 
chin  to  the  vertex  of  the  skull,  an  occipitofrontal  circle,  and  a 
horizontal  circle  from  the  front  of  the  chin  to  the  back  of  the  neck. 
It  is  employed  to  draw  the  chin  upward  and  backward  in  fractures 
of  the  lower  jaw,  but  it  is  less  satisfactory  than  either  the  four- 
tailed  or  the  Barton  bandage. 

The  bandage  is  started  at  the  vertex  at  or  in  front  of  the 
coronal  suture,  and  is  carried  in  front  of  the  left  ear,  under  the 


Fig.  -330. — Gibson's  Bandage  for  Fracture  of  the  Lower  Jaw,    Showing  the 

First  Reverse. 

chin,  and  in  front  of  the  right  ear  and  back  to  the  starting-point. 
Two  additional  turns  are  made  directly  over  the  first  one.  A 
fourth  vertical  turn  is  then  started,  but  when  it  reaches  the  occipito- 
frontal circle  the  bandage  is  reversed  (Fig.  330),  and  carried  three 
times  around  this  circle.  A  fourth  horizontal  turn  is  started,  but 
when  the  bandage  reaches  the  occiput,  it  is  carried  forward  below 
the  right  ear,  across  the  front  of  the  chin,  and  backward  below 
the  left  ear  to  the  occiput.  Two  additional  turns  of  this  character 
are  applied.  When  it  reaches  the  occiput,  the  bandage  is  reversed 
41 


Fig.  331. 


-Gibson's  Bandage  Complete,  Exc 
sections. 


il;   'I  HE    PlNI 


the  Inter. 


Fig.  332. — Figure  of  Eight  Bandage  of  the  Forehead  and  Chin.     The  occipito- 
frontal circle  is  complete,  and  the  occipitomental  circle  is  nearing  completion. 
612 


FIGURE   OF   EIGHT    BANDAGE    OF   HEAD   AND    NECK        613 

again  and  carried  in  the'median  line  over  the  vertex  of  the  skull 
to  the  forehead  (Fig.  331).  The  extremity  is  there  stitched  or 
pinned,  as  are  all  the  intersections  of  the  bandage — seven  in  all. 

No.  15.  Figure  of  Eight  of  the  Forehead  and  Chin; 
a  One  and  One-half  Inch  Bandage.  — The  area  covered  by  this 
bandage  is  made  up  of  two  circles.  One  is  the  occipitofrontal 
circle  above  the  ears  and  the  other  the  occipitomental  circle  below 
the  ears.  It  is  of  use  to  control  hemorrhage  or  to  keep  in  place 
a  dressing  of  the  lower  occipital  region. 

The  bandage  is  started  on  the  forehead  and  carried  around 
the  head,  above  the  ears,  to  the  starting-point.  This  anchors  the 
bandage.  It  is  then  carried  above  one  ear  to  the  occiput,  and  from 
there  describes  a  circle  below  both  ears  and  across  the  point  of 
the  chin,  and  back  to  the  occiput  (Tig.  332).  From  there  it  de- 
scribes alternately  the  frontal  and  mental  circles,  each  two  or  three 
times. 

BANDAGES   OF   THE    NECK    AND    AXILLA,   ALONE   AND   IN 

COMBINATION 

No.  16.     Circular  of  the  Neck;  a  Two  Inch  Bandage. 

— The  area  covered  by  this  bandage  is  a  circle  around  the  neck. 
It  is  of  use  to  fix  a  dressing  within  this  area. 

The  bandage  is  started  at  the  back  of  the  neck,  and  is  carried 
around  the  neck  till  the  starting-point  is  reached.  This  anchors 
the  bandage.  Two  or  three  additional  turns  are  applied  (Fig. 
333)  and  the  bandage  is  complete. 

It  is  sometimes  possible  to  increase  the  area  covered  by  this 
bandage  by  making  of  it  an  ascending  or  descending  spiral.  It  is 
usually  better  under  such  circumstances  to  employ  the  combined 
head  and  neck  bandage,  or  the  combined  bandage  of  the  neck  and 
axilla. 

No.  17.  Posterior  Figure  of  Eight  of  Head  and  Neck ; 
a  Two  Inch  Bandage. — The  area  covered  by  this  bandage  is 
composed  of  two  circles — the  occipitofrontal  circle  and  the  circle 
of  the  neck. 

The  bandage  is  started  on  the  forehead  and  carried  around 
the  head,  above  both  ears,  to  the  starting-point.  This  anchors 
the  bandage.  It  is  continued  in  the  same  circle  to  the  occiput, 
and  is  then  carried  around  the  neck  to  the  occiput   (Fig.  334). 


V-       *t* 

A 

v 

)^ 

Fig.  333. — Circular  Bandage  of  Neck. 


Fig.  334. — Posterior  Figure  of  Eight  Bandage  of  Head  and  Neck.      The  occi 
pitofrontal  turn  is  completed,  and  the  cervical  turn  js  nearly  completed 
614 


FIGURE   OF   EIGHT   BANDAGE   OF   HEAD   AND   NECK       615 

These  occipitofrontal  and  cervical  turns  are  continued  alternately 
two  or  three  times.  The  addition  of  two  or  three  turns  around 
the  neck  will  carry  the  bandage  farther  down  the  back  of  the  neck, 
should  this  be  necessary. 

No.  18.  Anterior  Figure  of  Eight  of  Head  and  Neck; 
a  Two  Inch  Bandage. — The  area  covered  by  this  bandage  is  the 
horizontal  circle  of  the  neck,  the  under  surface  of  the  chin,  the 
angle  of  the  jaw,  the  cheek  on  one  or  both  sides,  the  mastoid  region 
on  one  or  both  sides,  and  the  vertex  of  the  skull.  It  is  especially 
useful  to  keep  in  place  dressings  of  the  front  and  sides  of  the 
neck  which  extend  too  high  for  the  circular  bandage  of  the  neck. 


Fig.  335. — Anterior  Figure  of  Eight  Bandage  of  the  Head  and  Neck,  Showing 
the  Formation  of  the  Second  Loop. 


The  bandage  is  started  on  the  front  of  the  neck  and  is  carried 
toward  the  affected  side,  around  the  neck  to  the  starting-point. 
This  anchors  the  bandage.  A  second  circular  turn  is  made  slightly 
above  the  first.  A  third  turn  is  started,  but  when  it  .reaches  the 
side  of  the  neck  it  is  carried  over  the  top  of  the  head,  either  in 


016 


THE   HOLLER    BANDAGE 


Cn  'in  of  or  behind  the  ear,  according  to  circumstances  (Fig.  335). 
If  it  is  carried  in  front  of  the  oar.  it  must  descend  behind  the 
opposite  ear  to  the  starting-point.  If  it  is  carried  behind  the  ear, 
it  may  descend  either  in  front  of  or  behind  the  opposite  ear.  The 
fourth  turn  of  the  bandage  again  encircles  the  neck.  The  fifth 
turn  is  carried  over  the  head.  These  alternate  until  the  bandage 
is  complete. 

This  bandage  is  rendered  firmer  by  the  addition  of  the  hori- 
zontal circular  bandage  of  the  head  (No.  1),  with  pinning  or 
stitching  of  the  intersections. 

No.  19.  Figure  of  Eight  of  Neck  and  Axilla  ;  a  Two 
Inch  Bandage. — The  area  covered  by  this  bandage  is  the  hori- 


Fig.  336. — Figure  of  Eight  Bandage  op  Neck  and  Axilla.      The  bandage  has 
been  anchored  around  the  neck,  and  the  figure  of  eight  turn  is  almost  complete. 


zontal  circle- of  the  neck,  the  axilla,  and  the  upper  portion  of  the 
shoulder.     It  is  useful  to  keep  in  place  a  dressing  of  the  axilla, 


FIGURE  OF  EIGHT   BANDAGE   OF  NECK  AND  AXILLA      617 

and  also  to  hold  a  dressing  of  the  neck  lower  down  at  the  side  than 
is  possible  with  the  circular  bandage  of  the  neck. 

The  bandage  is  started  on  the  front  of  the  neck,  and  is  carried 
around  the  neck  to  the  starting-point.  This  anchors  the  bandage. 
A  second  circular  turn  is  made  slightly  below  the  first.     A  third 


Fig.  337. 


-Figure  of  Eight  Bandage  of  Neck  and  Axilla,  Showing  the  Addition 
of  Simple  Turns  to  Increase  Its  Lateral  Area. 


turn  is  started,  but  when  it  reaches  the  affected  side,  it  is  carried 
over  the  shoulder,  under  the  arm,  and  up  over  the  shoulder  to  the 
front  of  the  neck  (Fig.  336),  and  so  on  around  to  the  starting- 
point.  By  repeating  this  figure  of  eight  turn  two  or  three  times 
it  is  possible  to  make  the  bandage  progress  a  little  in  one  direction 
or  another,  so  as  to  increase  somewhat  the  area  covered  upon  the 
neck  and  axilla.  If  it  is  desired  to  extend  the  bandage  still  farther 
forward  or  backward,  several  simple  turns  should  be  made  around 
the  neck  and  under  the  arm  (Fig.  337).     If  it  is  desired  to  extend 


61S 


THE    ROLLER    1UNDAUE 


the  bandage  farther  down  the  arm,  it  should  be  combined  with  the 
descending  spica  of  the  shoulder  (  No.  35).  If  it  is  desired  to 
extend  the  bandage  still  farther  to  the  front  or  back,  it  should  be 
combined  with  tin-  anterior  or  posterior  figure  of  eight  of  the  chest, 
as  the  case  may  be.  This  combination  is  described  under  the 
name  "  complete  bandage  of  the  neck''  (Xo.  22),  of  which  the 
figure  of  eight  of  neck  and   axilla  forms  an  important  part. 

No.  20.  Figure  of  Eight  of  Both  Axillae ;  a  Two 
Inch  Bandage. — The  area  covered  by  this  bandage  is  composed 
of  both  axillae  and  the  lower  portion  of  the  neck.     It  is  useful  in 


Fig.  33S. — Figure  of  Eight  Bandage  of  Both  Axillae.      As  shown  in  the  figure,  the 
bandage  is  almost  complete. 

holding  a  dressing  in  the  axilla,  or  in  keeping  an  axillary  pad 
in  place  in  cases  of  fracture  of  the  clavicle  or  of  fracture  of  the 
upper  end  of  the  humerus. 

The  bandage  is  started  at  the  left  side  of  the  neck,  close  to  the 
shoulder,  and  is  carried  across  the  front  of  the  left  shoulder,  and 


OBLIQUE  CIRCULAR   BANDAGE   OF   NECK   AND   AXILLA      619 

backward  across  the  left  axilla  and  to  the  starting-point.  This 
anchors  the  bandage.  It  is  next  carried  across  the  front  of  the 
chest  to  the  right  axilla,  backward  across  the  right  axilla,  and 
over  the  top  of  the  right  shoulder,  and  across  the  front  of  the 
chest  to  the  left  axilla.  It  is  carried  across  the  left  axilla,  across 
the  back  to  the  top  of  the  right  shoulder,  over  the  front  of  this 
shoulder  (Fig.  338),  and  across  the  right  axilla,  and  from  there 
across  the  back  to  the  starting-point.  These  various  turns  may 
be  repeated  two  or  three  times.  This  gives  a  bandage  which 
leaves  the  head  and  neck  perfectly  free,  and  which  does  not  inter- 
fere with  the  wearing;  of  a  collar. 


Fig.  339. — Oblique  Circular  Bandage  of  the  Neck  and  Axilla,  Showing  a  Slight 
Progression  Upward  and  Downward. 

No.  21.  Oblique  Circular  of  Neck  and  Axilla;  a 
Two  Inch  Bandage. — The  area  covered  by  this  bandage  is  the 
central  portion  of  the  axilla.  It  is  useful  to  hold  a  dressing  in 
place.  If  a  more  extensive  bandage  of  the  axilla  is  required,  it 
will  be  found  in  JSTo.  23. 


620  THE  ROLLER   BANDAGE 

The  bandage  is  started  in  the  axilla,  is  carried  obliquely  up- 
ward across  the  back,  over  the  opposite  shoulder,  and  obliquely. 
downward  across  the  chest  to  the  starting-point.  This  anchors  the 
bandage.  Additional  turns  will  make  the  bandage  firmer,  and  they 
may  be  made  to  progress  a  little  upward  and  downward  in  the 
axilla  (Fig.  339),  but  if  carried  too  far  they  tend  to  slip  toward 
the  center  of  the  axilla. 

No.  22.  Complete  Bandage  of  the  Neck ;  a  Two 
Inch.  Bandage. — This  is  a  combination  of  the  occipitofrontal, 
the  anterior  and  posterior  figure  of  eight  of  the  head  and  neck,  the 
circular  of  the  neck,  and  the  figure  of  eight  of  the  neck  and  both 
axillae  (Nos.  1,  16,  17,  18,  and  20).  If  occasion  requires,  there 
may  be  added  to  these  the  figure  of  eight  of  the  chest,  both  an- 
terior and  posterior  (No.  21). 

The  area  covered  by  this  bandage  is  the  occipitofrontal  circle 
of  the  head,  the  back  of  the  head,  the  circle  of  the  ueck,  the  tops  of 
both  shoulders  and  both  axilla?,  and  possibly  the  upper  portion 
of  the  chest  both  front  and  back.  This  bandage  is  used  to  keep  a 
dressing  in  close  apposition  to  the  neck  after  an  extensive  dissection 
of  the  same. 

The  head  should  be  held  in  correct  relation  to  the  trunk.  The 
bandage  is  started  at  the  forehead,  and  is  carried  around  the  oc- 
cipitofrontal circle  to  the  starting-point.  This  anchors  the  band- 
age. It  is  carried  the  second  time  around  the  same  circle.  A 
third  turn  is  started,  but  when  this  reaches  the  ear  it  is  carried 
across  the  occiput  to  the  back  of  the  neck,  and  is  continued  around 
the  neck  in  the  same  direction,  at  least  twice,  each  succeeding  turn 
slightly  overlapping  the  first  one,  so  as  to  cause  the  bandage  to 
progress  from  the  center  downward  (Fig.  310).  When  the  band- 
age next  reaches  the  back  of  the  neck  it  is  carried  upward  across 
the  occiput  to  the  starting-point  on  the  forehead.  These  three 
turns — the  circle  of  the  head,  the  figure  of  eight  of  the  head  and 
neck,  and  the  circle  of  the  neck — are  again  repeated,  or  twice,  if 
necessary. 

The  bandage  thus  far  applied  serves  to  fix  the  head  upon  the 
neck,  and  to  hold  a  dressing  at  the  back  of  the  neck.  To  complete 
this  fixation  and  to  hold  a  dressing  farther  forward  on  the  side 
of  the  neck,  the  anterior  figure  of  eight  bandage  of  the  head  and 
neck  (jSTo.  17)  should  be  applied.     The  vertical  turns  of  this  band- 


COMPLETE   BANDAGE   OF   THE   NECK 


621 


age  should  be  placed  both  in  front  of  and  behind  the  ear,  at  least, 
on  the  affected  side  (Fig.  341). 

The  next  step  in  the  application  of  this  bandage  is  the  fixation 
of  the  neck  and  trunk,  and  the  covering  of  the  lower  part  of  the 
dressing.     This  is  accomplished  as  follows :  An  additional  bandage 


Fig.  340. — Complete  Bandage  of  the  Neck  at  an  Early  Stage. 

is  anchored  by  starting  it  at  the  back  of  the  neck  and  carrying  it 
once  or  twice  around  the  neck  to  the  starting-point.  The  third  turn 
is  started,  but  when  it  is  passed  just  beyond  the  top  of  the  right 
shoulder  it  is  carried  under  the  arm  from  in  front  backward,  is 
brought  again  to  the  top  of  the  shoulder,  and  from  there  to  the 
front  of  the  neck.  From  there  it  is  carried  to  the  top  of  the  left 
shoulder,  and  is  passed  under  that  arm  from  behind  forward,  and 
thence  to  the  top  of  the  shoulder  and  the  back  of  .the  neck.  This 
part  of  the  bandage,  which  is  a  figure  of  eight  of  both  axillae,  but 
a  variation  of  bandage  ISTo.  20,  is  repeated  three  or  four  times,  as 


622 


THE   ROLLER   BA.NDAdK 


may  be  necessary.     Figure   341    shows   the   bandage   in   outline. 

The  dressing  has  now  been  fixed  ;it   both  sides;  if  it   requires 

additional  fixation  in  front  and  behind,  this  is  to  be  accomplished 

by  the  addition  of  figure  of  eight   turns  of  the   front    and   hack 


Fig.  341. — Complete  Bandage  of  the  Neck  Applied  in  Skeleton  Form  with  a 
Narrow  Bandage  to  Show  the  Various  Turns. 


of  the  chest.  Suppose  the  bandage  to  have  reached  the  back  of 
the  neck,  having  just  completed  the  figure  of  eight  of  the  left 
axilla  (Fig.  341).  It  is  then  carried  across  the  back  of  the  shoul- 
ders, beneath  the  right  arm  to  the  top  of  the  right  shoulder,  across 
the  back,  beneath  the  left  arm,  and  above  the  left  shoulder  to 
the  starting-point.  (Compare  Fig.  345.)  This  figure  of  eight  is 
repeated  two  or  three  times,  as  may  be  necessary.  The  bandage 
is  carried  under  the  arm  from  front  to  hack,  over  the  shoul- 
der, and  to  the  front  of  the  neck,  under  the  left  arm,  from  in 
front  backward,  over  the  left  shoulder,  and  to  the  front  of  the 


COMPLETE   BANDAGE   OF  THE  AXILLA  623 

neck.  (Compare  Fig.  344.)  This  figure  of  eiglit  turn  is  repeated 
two  or  three  times,  as  may  be  necessary,  and  the  bandage  is 
complete. 

If  a  soft  bandage  is  employed,  the  intersections  on  the  head 
should  be  stitched  or  pinned.  If  the  bandage  which  is  applied 
becomes  rigid — for  example,  starch  or  plaster  of  Paris — it  is  a 
good  plan  to  cut  away,  after  the  bandage  has  become  dry,  such 
portions  of  it  as  pass  beneath  the  arms  crossing  in  the  axillae. 
This  does  not  materially  lessen  the  fixation  of  the  head  and  neck, 
and  it  adds  greatly  to  the  patient's  comfort.  If  the  bandage  is 
a  soft  one,  it  may  likewise  be  cut  away  and  fastened  to  the  chest, 
both  in  front  of  and  behind  each  arm,  by  strips  of  adhesive 
plaster. 

In  many  cases  it  will  not  be  necessary  to  fix  the  bandage  of 
the  neck  to  the  chest  on  both  sides  and  in  front  and  behind.  It 
was  thought  better,  however,  to  describe  the  full  bandage,  and  to 
leave  to  the  ingenuity  of  the  physician  the  omission  of  a  portion 
of  it,  according  to  circumstances. 

No.  23.  Complete  Bandage  of  the  Axilla;  a  Two 
Inch  Bandage. — The  area  covered  by  this  bandage  is  the  whole 
region  of  the  axilla  from  the  inner  surface  of  the  arm  to  the  outer 
surface  of  the  chest.  According  to  circumstances,  portions  of  the 
bandage  may  be  omitted.  It  is  of  use  to  hold  a  dressing  in  the 
axilla. 

This  bandage  (Fig.  342)  is  composed  of  six  parts:  A,  the 
spiral  of  the  arm  (No.  36)  ;  B,  the  ascending  spica  of  the  shoul- 
der (No.  34)  ;  C,  the  figure  of  eight  of  the  neck  and  axilla  (No. 
19)  ;  D,  the  oblique  circular  of  the  neck  and  axilla  (No.  21)  ; 
E,  the  descending  spica  (No.  35)  of  the  opposite  shoulder,  and  F, 
the  descending  spiral  of  the  chest  (No.  27). 

A.  The  bandage  is  started  on  the  arm,  near  the  shoulder,  and 
is  carried  across  the  outer  surface  of  the  arm  from  before  back- 
ward, and  anchored  by  a  circular  turn.  It  is  then  carried  spi- 
rally upward. 

B.  As  soon  as  the  swelling  of  the  shoulder  interferes  with  the 
spiral,  the  bandage  is  carried  over  the  shoulder,  obliquely  down- 
ward across  the  back,  under  the  opposite  arm,  obliquely  upward 
across  the  chest  and  over  the  shoulder  and  into  the  axilla.  Two 
or  three  of  these  figure  of  eight  turns  are  applied,  each  a  little 


C>24 


THE    ROLLER    BANDAGE 


higher  up  on  the  affected  shoulder,  while  exactly  overlapping  its 
predecessor  under  the  opposite  arm. 

C.  The  portion  of  the  axilla  nearer  the  chest  is  next  covered 
in  by  a  figure  of  eight  of  the  axilla  and  neck. 


Fig.  342. — Complete  Bandage  of  the  Axilla,  Composed  of  Six  Parts:  A,  The 
Spiral  of  Arm;  B,  The  Spica  of  the  Shoulder;  C,  Figure  of  Eight  of  the 
Neck  and  Axilla;  D,  The  Oblique  Circular  of  Neck  and  Axilla;  E,  The 
Descending  Spica  of  the  Opposite  Shoulder;  and  F,  The  Descending  Spiral 
of  the  Chest.  In  the  illustration  the  bandage  employed  is  purposely  too  narrow, 
and  the  area  is  only  partially  covered  in  order  that  these  different  parts  of  the 
bandage  may  be  the  more  readily  recognized. 


D.  The  portion  of  the  axilla  next  lower  on  the  chest  is  then 
covered  by  oblique  circular  turns  passing  from  the  axilla  ob- 
liquely upward  across  the  back  to  the  opposite  side  of  the 
neck,    and    obliquely    downward    across    the   chest   to    reach    the 


axilla  again. 


E.   The  next  lower  portion  of  the  axilla  is  covered  by  figure 
of  eight  turns  of  the  bandage  which  cross  on  the  opposite  shoulder 


FIGURE   OF  EIGHT   BANDAGE   OF   NECK   AND  CHEST 


625 


and  pass  under  the  opposite  arm.  This  figure  of  eight  is  the  de- 
scending spica  of  the  opposite  shoulder. 

F.  The  bandage  may  be  carried  still  farther  downward  along 
the  chest  by  a  descending  spiral  of  the  chest. 

No.  24.  Anterior  Figure  of  Eight  of  Neck  and 
Chest ;  a  Two  and  One  Half  Inch  Bandage. — The  area  cov- 
ered by  this  bandage  is  the  neck,  the  front  of  the  chest,  and  the 
circle  of  the  chest  below  the  arm.  It  is  a  combination  of  a  circular 
bandage  of  the  neck,  a  circular  bandage  of  the  chest,  and  a  figure 
of  eight  connecting  the  two.  The  bandage  is  used  to  keep  a 
dressing  in  place  on  the  front  of  the  chest.     It  has  certain  advan- 


Fig.  343. — Anterior  Figure  of  Eight  Bandage  of  the  Neck  and  Chest,  Showing 
the  Horizontal  Turn  of  the  Chest,  and  the  Completion  of  the  Figure  of 
Eight  Turn. 


tages  over  the  anterior  figure  of  eight  of  the  chest  (E"o.  25)  in  that 
it  does  not  confine  the  arms. 

The  bandage  is  started  at  the  front  of  the  neck,  and  is  carried 


626  THE  ROLLER    BANDAGE 

around  the  neck  in  either  direction — say  to  the  left  as  it  crosses 
the  front  of  the  neck,  then  backward  to  the  right,  and  forward 
again  to  the  starting-point.  The  bandage  is  then  carried  obliquely 
across  the  chest,  under  the  left  arm,  across  the  back  of  the  chest, 
under  the  right  arm,  and  then  horizontally  once  around  the  chest 
beneath  both  arms.  When  it  reaches  the  front  of  the  chest  it  is 
carried  obliquely  upward,  over  the  left  shoulder  (Fig.  343),  and 
so  on  around  the  back  of  the  neck  to  the  starting-point.  These 
horizontal  and  figure  of  eight  turns  are  repeated  three  or  four 
times  until  the  bandage  is  sufficiently  firm.  It  is  well  to  fasten 
the  oblique  turns  to  the  horizontal  turns  around  the  chest  with 
safety  pins,  so  that  they  shall  not  draw  up  against  the  anterior 
axillary  folds. 

The  posterior  figure  of  eight  of  the  neck  and  chest  is  exactly 
like  the  anterior  bandage,  excepting  that  it  is  started  at  the  back 
of  the  neck  and  crosses  the  back  of  the  chest  instead  of  the  front. 


BANDAGES   OF   THE   TRUNK 

No.  25.  Anterior  Figure  of  Eight  of  Chest ;  a  Two 
Inch  or  a  Three  Inch  Bandage.  — The  area  covered  by  this 
bandage  is  the  upper  portion  of  the  front  of  the  chest  and  two 
loops,  one  around  each  shoulder.  It  is  of  use  to  keep  a.  dressing 
in  place  on  the  front  of  the  chest.  It  is  also  used  in  combination 
with  the  bandage  of  the  neck  to  hold  in  place  the  lower  part  of  a 
dressing  of  the  neck.  It  may  also  be  combined  with  the  spiral 
bandage  of  the  chest. 

The  bandage  is  started  at  the  upper  end  of  the  sternum  and 
carried  over  either  shoulder,  say  the  right  one.  It  is  then  carried 
under  the  right  arm  and  back  to  the  starting-point.  This  anchors 
the  bandage.  It  is  then  carried  over  the  left  shoulder  and  under 
the  left  arm  to  the  starting-point  (Fig.  344).  This  completes 
the  figure  of  eight.  The  bandage  is  carried  over  this  course 
two  or  more  times.  The  crossings  on  the  chest  may  overlap  a 
little  to  increase  the  area  of  the  bandage  either  upward  or 
downward. 

No.  26.  Posterior  Figure  of  Eight  of  Chest ;  a  Two 
Inch  or  a  Three  Inch  Bandage.  — The  area  covered  by  this 
bandage  is  the  upper  portion  of  the  back  of  the  chest  and  the 


POSTERIOR   FIGURE   OF  EIGHT   BANDAGE   OF  CHEST       627 

backs  and  fronts  of  both  shoulders.  It  is  of  use  to  keep  a  dress- 
ing in  place  on  the  back  of  the  chest  or  the  back  of  the  shoulder. 
It  may  be  used  in  combination  with  the  bandage  of  the  neck 
(No.  22),  to  hold  in  place  the  lower  part  of  the  dressing  of  the 
neck.  It  may  also  be  combined  with  the  spiral  bandage  of  the 
chest  (No.  27).  It  is  sometimes  applied  in  plaster  of  Paris  for 
fixation  of  the  shoulders  after  fracture  of  the  clavicle. 


Fig.  344. — Anterior  Figure  of  Eight  Bandage  of  Chest,  Showing  the  Comple 
tion  of  the  Figure  of  Eight. 


The  bandage  is  started  at  the  base  of  the  neck  behind  and  is 
carried  over  the  right  shoulder.  It  is  then  carried  under  the  right 
arm  and  across  the  back  of  the  shoulder  to  the  starting-point. 
This  anchors  the  bandage.  It  is  then  carried  over  the  left  shoul- 
der, under  the  left  arm,  and  across  the  back  of  the  left  shoulder 
to  the  starting-point  (Fig.  345).  This  completes  the  figure  of 
42 


628 


THE    ROLLER    BAXDACiE 


eight. 


Two  or  three  additional  figure  of  eight  turns  complete  the 
bandage.  By  overlapping  these  upon  the  hack  one  can  increase 
the  area  covered  by  the  bandage  either  upward  or  downward. 


Fig.  345. — Posterior  Figure  of  Eight  Bandage  of  Chest,  Showing  the  Com- 
pletion of  the  Figure  of  Eight. 

No.  27.  Descending  Spiral  of  Chest ;  a  Three  Inch 
or  Four  Inch  Bandage.  — The  area  covered  by  this  bandage  is 
the  complete  area  of  the  chest  below  the  horizontal  line  which 
passes  under  both  arms.  It  is  of  use  to  keep  a  dressing  in  place 
anywhere  within  this  region.  If  it  is  necessary  that  the  bandage 
should  extend  higher  the  spiral  of  the  chest  should  be  combined 
with  the  anterior  or  posterior  figure  of  eight  of  the  chest,  or  with 
both  (jSTos.  25  and  26).  If  it  is  necessary  that  the  bandage  should 
extend  lower,  the  spiral  of  the  chest  should  be  combined  with  the 
descending  spiral  of  the  abdomen  (No.  32). 


DESCENDING  SPIRAL   BANDAGE   OF  rni.-i 


629 


The  spiral  of  the  chest  may  be  an  ascending  or  descending 
spiral.  The  latter  will  be  described.  The  bandage  is  started  a 
little  above  the  center  of  the  sternum,  and  is  carried  horizontally 
around  the  chest,  just  below  the  arms,  to  the  starting-point.  This 
anchors  the  bandage.  A  second  turn  exactly  overlies  the  first. 
A  third  turn  overlaps  the  second  at  its  lower  edge  sufficiently  so 
that  when  it  is  carried  around  to  the  sternum  it  shall  be  an  inch 
lower  down  (Fig.  346).     The  fourth  turn  is  parallel  to  the  third, 


Fig.  346. — Descending  Spiral  Bandage  of  the  Chest,  Showing  the  Completion 
of  the  First  Spiral  Turn. 


the  fifth  to  the  fourth,  and  so  on  until  the  chest  is  covered  (Fig. 
347).  The  bandage  is  completed  by  a  circular  turn.  This  band- 
age is  liable  to  slip  downward  unless  held  in  place  by  two  shoulder- 
straps,  stitched  or  pinned  to  all  the  turns  of  the  bandage. 


630 


THE    ROLLER    BANDAGE 


Ascending  Spiral  of  Chest.- — The  ascending  spiral  is  similar, 
excepting  that  the  bandage  is  started  a1  the  epigastrium,  anchored 
by  two  horizontal  turns,  and  carried  spirally  upward. 


Fig.  347. — Descending  Spiral  Bandage  of  the  Chest  Complete. 


No.  28.  Spica  of  One  Breast;  a  Three  Inch  Band- 
age.— The  area  covered  by  this  bandage  is  the  circle  of  the  lower 
portion  of  the  chest,  one  breast,  the  back  of  the  shoulder  on  the 
same  side,  and  the  top  of  the  opposite  shoulder.  It  is  of  use  to 
support  and  make  pressure  upon  one  breast,  or  to  retain  a  dressing 
in  position. 

Supposing  the  right  breast  is  to  be  bandaged.  The  bandage 
is  started  over  the  lower  portion  of  the  sternum  and  carried  hori- 
zontally across  the  left  side  of  the  chest,  the  back,  the  right  side 
of  the  chest,  and  to  the  starting-point.  This  anchors  the  band- 
age. A  second  turn  is  carried  directly  over  the  first  one  until  the 
right  side  of  the  chest  is  reached.  It  is  then  carried  obliquely 
upward,  slightly  overlapping  the  lower  margin  of  the  right  breast, 
over  the  left  shoulder   (Fig.   348),  across  the  back  of  the  right 


SPICA   BANDAGE   OF   ONE    BREAST 


631 


shoulder,  under  the  right  arm,  and  to  the  sternum,  one  inch  above 
the  starting-point.  It  is  again  carried  horizontally  around  the 
chest  parallel  to  the  previous  horizontal  turn,  and  obliquely  up- 
ward across  the  breast,  an  inch  above  the  previous  oblique  turn. 
As  the  bandage  passes  over  the  left  shoulder  this  overlapping 
should  be  reduced  to  half  an  inch  or  less,  as  the  space  here  is 
limited.  These  alternating  horizontal  and  oblique  turns  are  con- 
tinued until  the  breast  is  both  elevated  and  compressed  (Fig.  349 J. 
The   oblique   turns   should  not   be   carried  very  much  above  the 


Fig.  348. 


-Spica  Bandage  of  One  Breast.     The  bandage  is  anchored  and  the  first 
oblique  turn  is  applied. 


nipple,  but  the  horizontal  turns  should  extend  to  the  upper  margin 
of  the  breast.  A  properly  applied  breast  bandage  should  support 
the  whole  weight  of  the  breast,  thus  relieving  all  strain  upon  its 


632 


I  in:    UoLLEli    BANDAGE 


attachments.  If  circumstances  render  it  desirable,  the  nipple  can 
be  allowed  to  protrude  between  the  turns  of  the  bandage,  or  a 
circular  opening  may  be  cut  for  it  after  the  bandage  is  completed. 


Fig.  349. — Spica  Bandage  of  One  Breast  Completed. 


No.  29.  Spica  of  Both  Breasts  ;  a  Three  Inch  Band- 
ag*e. — The  area  covered  by  this  bandage  is  the  circle  of  the  lower 
portion  of  the  chest,  both  breasts,  and  the  backs  and  tops  of  both 
shoulders.  It  is  of  use  to  support  and  make  pressure  upon  both 
breasts  or  to  retain  a  dressing  in  jDosition. 

In  bandaging  one  breast,  the  bandage  should  invariably  be 
carried  from  the  lower  edge  of  the  breast  to  the  opposite  shoulder. 
In  this  way  the  drag  of  the  bandage  is  upward,  and  tends  to  lift 
the  breast  with  it.  In  bandaging  both  breasts  with  a  single  band- 
age, it  is  necessary  to  approach  one  breast  in  the  opposite  direc- 


SPICA   BANDAGE   OF   BOTH    BREASTS 


633 


tion.  The  latter  should,  of  course,  be  the  breast  less  affected. 
In  the  following  description,  the  left  breast  is  assumed  to  be  more 
affected  than  the  right. 

The  bandage  is  started  over  the  lower  portion  of  the  sternum 
and  carried  horizontally  across  the  right  side  of  the  chest,  the  back, 
the  left  side  of  the  chest,  and  to  the  starting-point.  This  anchors 
the  bandage.  A  second  turn  is  carried  directly  over  the  first  one 
until  the  left  side  of  the  chest  is  reached.  The  bandage  is  then 
carried  obliquely  upward,  slightly  overlapping  the  lower  margin 
of  the  left  breast,  over  the  right  shoulder,  across  the  back  of  the 


Fig.  350. — Spica  Bandage  of  Both  Breasts.  Three  oblique  turns  of  both  breasts 
are  completed.  The  second  breast  to  be  bandaged  should  be  lifted  each  time  the 
bandage  comes  down  across  it  to  prevent  a  downward  drag. 

left  shoulder,  under  the  left  arm,  and  to  the  starting-point.     It 
is  then  carried  horizontally  to  the  right  side,  across  the  back  over 


634 


THE   HOLLER    BANDAGE 


the  left  shoulder,  obliquely  downward  across  the  chest,  slightly 
overlapping  the  lower  margin  of  the  righ.1  breast,  which  should 
he  lifted  as  the  bandage  crosses  it,  so  as  to  avoid  a  downward  drag 
of  the  bandage. 

The  bandage  is  next  carried  across  the  right  side,  across  the 
back,  across  the  left  side,  one  inch  above  the  previous  turns,  ob- 


Fig.  351. — Spica  Bandage  of  Both  Breasts.     The  oblique  turns  have  been  com- 
pleted, and  the  serpentine  turns  for  compression  are  nearing  completion. 


liquely  upward  across  the  left  breast,  over  the  left  shoulder,  across 
the  left  side,  and  horizontally  around  the  chest  one  inch  above 
the  previous  horizontal  turn.  When  the  bandage  reaches  the  back, 
it  is  carried  obliquely  upward  over  the  left  shoulder,  and  obliquely 
downward  over  the  right  breast.  These  turns  are  continued  until 
the  bandage  has  passed  three  times  over  each  shoulder  (Fig.  350). 


VELPEAU'S    BANDAGE 


635 


The  overlapping  on  the  shoulder  should  not  exceed  half  an  inch, 
as  the  space  there  is  limited.  When  the  bandage  has  reached  this 
stage,  both  breasts  will  have  been  supported  and  compressed  from 
below.  The  bandage  should  not  be  completed  by  four  serpentine 
turns  around  the  chest,  the  first  one  of  which  passes  beneath  the 
left  breast'  and  above  the  right  breast ;  the  second  one  above  the  left 
breast  and  beneath  the  right  breast.  The  third  follows  the  course 
of  the  first,  but  is  placed  nearer  to  the  nipple  of  each  breast,  and 
the  fourth  follows  the  course  of  the  second,  but  is  placed  nearer  the 
nipple  of  each  breast  (Fig.  351). 

~No.  30.  Velpeau;  a  Figure  of  Eight  of  the  Chest 
and  Shoulder;  a  Two  and  One-Half  Inch  Bandage. — 
The  area  Covered  by  this  bandage  is  the  whole  chest  below  the 


Fig.  352. — Velpeau's  Bandage.     The  first  turn  is  nearly  completed.     Note  that  the 
bandage  has  been  turned  over  in  oi'der  to  avoid  twisting  it  under  the  arm. 

arms,  one  shoulder,  and  the  whole  of  the  corresponding  arm,  ex- 
cept the  hand.    It  is  of  use  to  fix  the  arm  firmly  to.  the  chest  after 


636 


THE   1JULLER   BANDAGE 


fracture  of  the  clavicle  or  scapula   or  after  a  dislocation  of  the 
shoulder  has  been  reduced. 

The  fiugers  of  the  arm  to  be  bandaged  should  be  placed  above 
the  opposite  clavicle.  Supposing  the  affected  arm  to  be  the  right 
one,  it  is  placid  in  the  position  indicated.  The  bandage  is  started 
at  the  angle  of  the  left  scapula  and  carried  upward  'over  the 
right  shoulder,  as  far  away  from  the  neck  as  possible.  It  is  then 
carried  down  the  front  of  the  shoulder  to  the  outer  side  of  the 
upper  arm,  beneath  the  elbow,  and  across  the  front  of  the  chest 
(Fig.  352).     Care  should  be  taken  nol  to  twist  the  bandage.     It 


Fig.  353. — Vklpkau's  Bandage.     Completion  of  one  oblique  and  one  circular  turn, 
and  beginning  of  second  oblique  turn. 


is  then  carried  under  the  left  arm  to  the  starting-point.  This 
anchors  the  bandage.  A  second  turn  is  applied  directly  over  the 
first,  but  when  the  left  side  is  reached,  the  bandage  is  carried 
horizontally  around  the  chest,  and  over  the  right  elbow,  thus 
fixing  the  arm  to  the  chest.     From  the  left  side  the  bandage  is 


DESAULT'S   BAN  J )A  GE 


637 


carried  obliquely  upward  across  the  back.  As  it  passes  over  the 
right  shoulder  it  should  overlap  the  previous  turn  one-half  inch  in 
the  direction  of  the  neck  (Fig.  353).  These  oblique  and  hori- 
zontal  turns    are    continued   alternately.      Each    horizontal    turn 


Fig.  354. — Velpeau's  Bandage,  Complete    Except   for   Two   Additional  Hori- 
zontal Turns  to  Complete  the  Ascending  Spiral. 


should  overlap  the  preceding  one  by  an  inch.  Four  oblique  turns 
over  the  shoulder  will  usually  bring  the  bandage  up  close  to  the 
neck  and  down  on  the  humerus  to  the  point  of  the  elbow.  The 
horizontal  portion  of  the  bandage  should  then  be  continued  spirally 
upward  as  far  as  the  left  arm  will  permit  (Fig.  354). 

"No.  31.  Desault's;  Three  Two  and  One-Half  Inch 
Bandages. — The  area  covered  by  this  bandage  is  the  whole  of  the 
chest  with  one  arm  bandaged  to  it:  the  opposite  axilla  and  both 
shoulders.  In  addition  the  hand  is  fixed  in  a  sling.  The  use 
of  this  bandage  is  to  fix  the  arm  to  the  chest,  to  press  the  affected 
shoulder  upward  and  backward,  and  to  support  the  arm.  It  is 
used  in  cases  of  fracture  of  the  clavicle. 


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638 


DESAULT'S   BANDAGE 


030 


Before  the  bandage  is  started,  a  wedge  shaped  pad  or  compress, 
with  its  base  at  least  an  inch  in  thickness,  is  placed  base  upward  in 
the  affected  axilla ;  say  the  left  one.  The  bandage  is  started  in 
the  center  of  the  axillary  pad,  and  is  carried  across  the  front  of  the 
chest,  over  the  right  shoulder,  under  the  right  arm,  over  the  right 


Fig.  357. — Desault's  Bandage  of  the  Chest  and  Arm.  This  shows  the  completion 
of  the  first  loop  of  the  third  roller.  It  is  a  triangle  of  which  the  oblique  sides  are  in 
front  of  the  chest,  and  the  vertical  side  behind.  The  second  loop,  yet  to  be  ap- 
plied, is  also  a  triangle,  the  oblique  sides  of  which  are  at  the  back  of  the  chest,  and 
the  vertical  side  in  front. 

shoulder,  and  across  the  back  of  the  chest  to  the  starting-point. 
This  anchors  the  bandage,'  and  prevents  the  pad  from  slipping 
down.  A  descending  spiral  of  the  chest  is  then  applied  until  the 
lower  limit  of  the  pad  is  reached.  The  bandage  is  then  carried 
spirally  upward  until  the  whole  pad  is  covered,  in.  The  figure 
of  eight  turn  across  the  right  shoulder  and  under  the  right  axilla 
with  which  the  bandage  was  started  should  now  be  repeated  to 
give  it  greater  firmness    (Fig.   355).      The  affected  left  arm  is 


040 


THE    ROLLER    BANDAGE 


Thru  broughl  closely  to  the  side,  and  the  forearm  is  flexed  to  n 
horizontal  level. 

The  second  roller  bandage  is  started  over  the  sternum  as  high 
as  the  unaffected  arm  will  permit,  and  is  carried  spirally  down- 
ward around  the  chesl  until  the  elbow  is  reached  (Fig.  35G).  The 
lower  turns  .of  this  roller  should  lie  applied  more  firmly  than  the 
upper  ones,  as  they  arc  intended  to  press  inward  the  elbow,  and  so 
to  pry  the  shoulder  outward  upon  the  pad,  which  acts  as  a  fulcrum. 

The  third  roller  is  started  in  the  right  axilla,  carried  across 
the  point  of  the  chest,  over  the  left  shoulder,  down  the  back  of  the 


Fig.  358. — Desault's  Bandage  of  the  Chest  and  Arm.  The  third  roller  is  used 
to  elevate  the  arm  by  means  of  two  loops  passed  under  the  elbow.  This  figure 
shows  the  completion  of  the  second  loop. 


left  arm,  under  the  left  elbow  and  obliquely  upward  across  the 
front  of  the  chest  to  the  starting-point  (Fig.  357).  This  anchors 
the  bandage,  which  is  now  directed  backward  instead  of  forward. 
It  is  then  carried  across  the  back  of  the  chest,  over  the  left  shoul- 


DESCENDING   SPIRAL   BANDAGE   OF   ABDOMKX 


641 


der,  down  the  front  of  the  left  arm,  under  the  left  elbow,  and 
obliquely  across  the  back  to  the  starting-point  in  the  right  axilla 
(Fig.  358).  These  two  loops  around  the  affected  arm  and  shoul- 
der are  repeated  three  times  for  greater  security. 

The  addition  of  a  sling  completes  the  bandage. 

No.  32.  Descending  Spiral  of  Abdomen ;  a  Three 
Inch  Bandage. — The  area  covered  by  this  bandage  is  the  abdo- 
men and  back.      It  is  of  use  to  keep  a  dressing  in  place  and  to 


Fig.  359. — Descending  Spiral  Bandage  of  Abdomen,  Showing  Its  Completion 
Below  the  Iliac  Crests. 

prevent  strain  on  a  suture  of  the  abdominal  wall  and  also  to  pre- 
vent the  escape  of  abdominal  organs  into  the  sac  of  an  umbilical 
or  a  ventral  hernia.  This  bandage  may  be  a  continuation  of  the 
descending  spiral  of  the  chest. 

The  bandage-  is  started  at  the  epigastrium,  and  is  carried  hori- 
zontally twice  around  the  trunk.  This  anchors  the  bandage.  The 
third  and  succeeding  turns  are  made  to  overlap  one  another  down- 
ward, each  for  a  distance  of  one  inch.     The  bandage  is  completed 


642 


THE    HOLLER    RAXDAOR 


a1  the  lower  portion  of  the  abdomen  by  a  circular  turn  (Fig.  359). 
This  bandage  should  extend  below  the  iliac  crests,  as  otherwise 
it  has  a  tendency  to  slip  apward.  The  individual  turns  should 
be  held  together  by  three  vertical  rows  of  stitches  or  narrow 
-trips  of  adhesive.  The  bandage  is  more  satisfactory  when  used 
upon  men  and  stout  women  than  it  is  upon  women  whose  waists 
are  very  much  smaller  than  their  hips. 

Ascending  Spiral  of  Abdomen. — An  ascending  spiral  bandage 
of  the  abdomen  is  similar  to  this  descending  spiral.  It  is  started 
below  the  iliac  crests,  anchored  by  two  circular  turns,  and  carried 
spirally  upward. 

No.  33.  Many  Tailed  Bandage  of  Abdomen  ;  a  Band- 
age Made  of  Six  or  Eight  Two  Inch  or  Wider  Strips, 
Each  About  One  Yard  Long.  — The  area  covered  by  this  band- 
age is  the  back  and  abdomen.     Its  use  is  to  keep  a  dressing  upon 


Fig.  360. — Many  Tailed  Bandage  Be- 
fore Its  Application,  Showing  Its 
Construction.  The  lateral  rows  of 
stitching  should  not  be  placed  farther 
forward  than  the  posterior  iliac  spines. 


Fig.  361. — Many  Tailed  Bandage  of 
the  Abdomen.  The  tails  are  brought 
forward  alternately,  and  each  one 
holds  the  one  before. 


ASCENDING  SPICA   BANDAGE   OF   SHOULDKH  643 

an  abdominal  wound  or  to  prevent  strain  of  a  sutured  wound.  If 
properly  made,  it  is  applicable  to  any  abdomen,  no  matter  how 
large  or  contracted.  The  bandage  is  made  of  strips  of  muslin  or 
canton  flannel,  the  width  of  which  should  vary  from  two  to  three 
inches,  according  to  the  size  of  the  patient.  Their  length  should 
be  equal  to  one  and  one-third  times  the  circumference  of  the  body 
at  the  iliac  crests.  The  strips  are  laid  parallel  on  a  table,  each 
strip  overlapping  the  adjacent  one  by  two-thirds  of  its  width,  like 
clapboards  on  the  side  of  a  house.  The  strips  are  fixed  in  this 
relation  by  three  rows  of  stitches ;  one  across  the  center  of  the 
strips,  and  the  other  two  from  four  to  six  inches  to  the  right  and 
left  (Fig.  360).  A  sufficient  number  of  strips  should  be  used  to 
give  a  bandage  which  will  extend  from  the  symphysis  to  the  ensi- 
for'm  cartilage.      Six  are  usually  sufficient. 

This  bandage  is  applied  by  placing  its  center  directly  over 
the  spine.  It  makes  no  difference  whether  the  strips  overlap 
upward  or  downward.  The  two  tails  of  the  strip  nearest  the 
body  are  crossed  over  the  abdomen  and  drawn  taut.  The  second 
tail  holds  the  first.  They  should  be  directed  slightly  toward  the 
opposite  edge  of  the  bandage  (Fig.  361).  The  third  tail  is  drawn 
across  the  second,  and  so  on  until  all  the  tails  are  in  place.  The 
last  one  must  be  pinned. 

BANDAGES  OF  THE  UPPER  EXTREMITY 

No.  34.  Ascending  Spica  of  Shoulder;  a  Two  Inch 
Bandage. — The  area  covered  by  this  bandage  is  the  upper  por- 
tion of  the  arm,  the  sides  and  outer  portion  of  the  shoulder,  and 
the  circle  of  the  neck.  It  is  of  use  to  keep  a  dressing  in  place 
and  also  to  make  a  shoulder-cap  out  of  a  plaster  of  Paris  bandage. 

The  bandage  is  started  in  the  middle  of  the  affected  arm,  and 
is  carried  around  the  arm  in  a  circle.  This  anchors  the  band- 
age, which  is  then  carried  spirally  upward  until  the  axillary 
folds  are  encountered.  The  bandage  is  then  carried  over  the 
outer  portion  of  the  shoulder,  around  the  chest,  under  the  oppo- 
site arm,  and  back  again  to  the  shoulder,  the  descending  portion 
of  the  bandage  crossing  the  ascending  exactly  midway  between 
the  front  and  back  of  the  affected  shoulder.  Another  circular 
turn  of  the  arm  is  made,  and  a  second  turn  around  the  chest. 
43 


644 


THE   ROLLEli    BANDAG] 


This  should  be  a  half  inch  higher  upon  the  shoulder  than  the 
preceding  figure  of  eight  turn,  but  on  the  opposite  side  of  the 
chest  it  may  exactly  overlie  the  preceding  one.     Three  or  four  addi- 


Fig.  362. — Ascending  Spica  Bandage  of  Shoulder  Complete. 

tional  figure  of  eight  turns  are  made,  without  an  intervening  circu- 
lar turn  around  the  arm  (Fig.  362).     This  completes  the  bandage. 

No.  35.  Descending  Spica  of  Shoulder;  a  Two  Inch 
Bandage. — The  area  covered  by  this  bandage  and  its  uses  are  the 
same  as  those  of  the  preceding  bandage. 

The  spica  bandage  can  be  made  to  descend  instead  of  ascend. 
After  the  arm  is  bandaged,  the  first  figure  of  eight  turn  over  the 
shoulder  and  around  the  chest  is  made  at  the  extreme  upper  point 
of  the  area  to  be  bandaged  (Fig.  363).  Each  successive  figure 
of  eight  turn  is  made  a  little  lower  on  the  affected  shoulder. 

No.  36.  Spiral  of  Arm;  a  Two  Inch  Bandage. — The 
area  covered  by  this  bandage  is  the  upper  arm  from  above  the 
elbow  to  the  shoulder. 


Fig.  363. — Descending  Spica  Bandage  op  the    Shoulder,  Showing  the    First 
Figure  op  Eight  Turn. 


Fig,  364. — Ascending  Spiral  Bandage  op  the  Upper  Arm. 

645 


646 


THE    ROLLER    BANDAGE 


This  bandage  is  used  to  keep  ;i  dressing  in  place  on  the  upper 
arm,  for  instance  after  vaccination;  and  also  to  retain  coaptation 
splints  after  fracture  of  the  shaft  of  the  humerus. 

It  is  anchored  by  a  circular  turn  above  the  elbow  and  wound 
spirallv  upward  (Fig.  364). 

No.  37.  Concentric  Figure  of  Eight  of  Elbow,  or 
Testudo  Inversa ;  a  Two  Inch  Bandage. — The  area  cov- 
ered by  this  bandage  is  the  region  of  the  elbow-joint.  It  may 
be  applied  when  the  joint  is  partially  or  fully  flexed.  It  is 
}\^(h\  to  keep  a  dressing  in  place  or  to  make  pressure  upon  the 
joint. 

The  bandage  is  fixed  by  two  circular  turns  around  the  upper 
part  of  the  forearm,  and  is  then  carried  obliquely  across  the  ante- 
rior surface  of  the  joint  and  around  the  upper  arm,  making  there 
a  complete  circular  turn  (Fig.  365).  It  is  then  brought  down 
over  the   anterior  surface  of  the  joint,   and  carried  around  the 


Fig.  365. — The  Concentric  Figure  of  Eight  Bandage  of  the  Elbow,  Showing 
the  Completion  of  the  First  Figure  of  Eight  Turn. 

forearm  a  little  higher  up  than  before.  These  figure  of  eight 
turns  are  repeated  until  the  elbow  is  covered,  each  one  being 
nearer  to  the  point  of  the  olecranon. 

No.  38.  Eccentric  Figure  of  Eight  of  the  Elbow,  or 
Testudo  Reversa  ;  a  Two  Inch  Bandage. — The  area  covered 
by  this  bandage  is  the  region  of  the  elbow-joint.    It  is  applied  when 


SPIRAL   REVERSE   BANDACE   OF    FOREARM 


047 


the  joint  is  partially  or  fully  flexed.    This  bandage  is  used  to  keep 
a  dressing  in  place  or  to  limit  the  motion  of  the  joint. 

The  bandage  is  fixed  by  two  circular  turns  directly  around  the 
elbow-joint,  and  passing  over  the  tip  of  the  olecranon.  As  the 
third  turn  reaches  the  olecranon,  it  is  carried  slightly  below  the 
second  turn,  but  exactly  overlies  it  again  at  the  front  of  the  elbow. 


Fig.  366. — The  Eccentric  Figure  of  Eight  Bandage  of  the  Elbow,  Showing 
the  Completion  of  the  Bandage. 

The  fourth  turn  is  carried  slightly  above  the  second  at  the  olecra- 
non, but  exactly  overlies  it  at  the  front  of  the  elbow.  This  proc- 
ess is  repeated,  each  turn  being  farther  and  farther  from  the 
olecranon  posteriorly  until  the  elbow  is  covered  (Fig.  366). 

If  this  bandage  is  applied  to  retain  the  arm  in  a  flexed  position, 
the  outermost  figure  of  eight  turns  should  alternate  with  circular 
turns  around  the  forearm  and  upper  arm.  In  this  manner  a  web 
is  formed  which  will  prevent  the  extension  of  the  joint.  This 
rigidity  is  much  greater  if  a  starch  bandage  is  used. 

No.  39.  Spiral  Reverse  of  Forearm;  a  Two  Inch. 
Bandage. — The  area  covered  by  this  bandage  is  the  forearm  from 
the  wrist  to  the  elbow.  It  is  used  to  keep  a  dressing  in  place  or  to 
affix  splints. 

The  bandage  is  fixed  by  a  circular  turn  at  the  wrist,  and  is 
carried  spiralty  upward.  After  two  or  three  turns,  depending  on 
the  shape  of  the  arm,  a  fulness  of  the  lower  edge  of  the  bandage 


64S 


Till:    KOLLEH    BANDAGE 


is  noticeable.  The  bandage  should  then  be  reversed  (Fig.  367) 
each  time  thai  il  is  brought  to  the  Eronl  of  the  arm.  The  upper 
part  of  the  forearm  is  often  of  uniform  size,  so  that  the  upper  por- 
tion of  the  bandage  may  be  a  simple  spiral.  The  reverses  should 
all  be  made  in  the  same  line,  cither  posteriorly  or  anteriorly. 


Fig.  367. — Spiral  Reverse  Bandage  of  Forearm,  Showing  the  First  Reverse. 

No.  40.  Figure  of  Eight  of  Forearm ;  a  Two  Inch 
Bandage. — The  area  covered  by  this  bandage  is  the  forearm  from 
the  wrist  to  the  elbow. 

The  bandage  is  fixed  by  a  circular  turn  at  the  wrist,  and  is 
carried  spirally  upward.  After  two  or  three  turns,  depending  on 
the  shape  of  the  arm,  the  lower  edge  of  the  bandage  is  looser  than 
the  upper.  The  spiral  is  then  changed  to  a  figure  of  eight.  The 
bandage  is  carried  upward  to  the  elbow,  and  circularly  around  the 
forearm,  just  below  this  joint.  It  is  then  brought  down  to  the 
point  where  the  spiral  was  discontinued  (Fig.  368).  A  circular 
turn  is  then  made,  and  following  this,  another  figure  of  eight  turn 
is  made  to  overlap  the  preceding  by  one-half  the  width  of  the 
bandage.     A  number  of  such  figure  of  eight  turns  are  made,  and 


Fig.  368. — Figure  of  Eight  Bandage  of  Forearm,  Showing  the  Completion  of 
the  First  Figure  of  Eight  Turn. 


Fig.  369. — Figure  of  Eight  Bandage  of  Forearm  Completed.      The  pattern  made 
by  a  spiral  reverse  bandage,  when  completed,  is  the  same  as  this. 

649 


650 


THE   KoLLEl;    BANDAGE 


the  covering  of  the  forearm  is  completed  by  two  or  three  circular 
turns  (Fig.  369).  The  crossings  of  the  figure  of  eight  turns  may 
be  either  upon  the  anterior  or  posterior  surface  of  the  forearm. 

No.  41.  Figure  of  Eight  of  the  Hand;  a  One  and 
One-Half  Inch  Bandage. — The  area  covered  by  this  bandage 
is  the  wrist,  the  back  of  the  hand,  and  the  palm  of  the  hand  with 
the  exception  of  a  small  portion  at  the  base  of  the  thumb.  It  is 
used  to  keep  a  dressing  in  place  or  to  affix  an  anterior  or  posterior 
sjilint. 

The  bandage  is  fixed  by  a  circular  turn  at  the  wrist,  and  is 
carried  across  the  back  of  the  hand  !<>  I  he  center  of  the  first  pha- 
lanx, or,  if  necessary,  clear  to  the  tips  of  the  fingers.  It  is  then 
carried  circularly  around  the  four  fingers,  and  then  spirally  up- 
ward. As  the  hand  is  reached,  the  bandage  is  carried  obliquely 
upward  across  the  back  of  the  hand  to  the  wrist,   around  which 


Fig.  370. 


-Figure  of  Eight  Bandage  of  the  Hand,  Showing  the  Completion  of 
the  First  Figure  of  Eight  Turn. 


a  circular  turn  is  made  (Fig.  370).  The  bandage  is  then  carried 
obliquely  downward  across  the  back  of  the  hand,  and  a  circular 
turn  is  made  around  the  hand  to  cover  the  triangular  gap  which 


SPIRAL   REVERSE    BANDAGE   OF   HAND 


651 


would  otherwise  be  left  bare.  Additional  figure  of  eight  turns 
are  then  applied,  each  overlapping  its  predecessor  upward  by  one- 
half  the  width  of  the  bandage.  The  thumb  should  not  be  included 
in  the  bandage  of  the  hand ;  if  it  is  desired  to  cover  it,  separate 
turns  for  the  purpose  should  be  made. 

No.  42.  Spiral  Reverse  of  Hand;  a  One  and  One- 
Half  Inch  Bandage. — The  area  covered  by  this  bandage  is  the 
wrist,  the  back  of  the  hand,  and  the  palm  of  the  hand  with  the 


Fig.  371. — Spiral  Reverse  Bandage  of  the  Hand  Showing  Two  Reverses. 

exception  of  a  small  portion  at  the  base  of  the  thumb.  It  is  used 
to  keep  a  dressing  in  place  or  to  affix  a  long  posterior  or  anterior 
splint. 

The  bandage  is  fixed  by  a  circular  turn  at  the  wrist,  and  is 
carried  across  the  back  of  the  hand  to  the  center  of  the  first  pha- 
lanx, or,  if  necessary,  clear  to  the  tips  of  the  fingers.  It  is  then 
carried  circularly  around  the  four  fingers  and  then  spirally  up- 
ward. As  the  hand  is  reached  the  bandage  is  reversed,  in  order 
to  make  it  fit  properly  (Fig.  371).  The  thumb  should  not  usually 
be  included  in  the  bandage.  If  it  is  desired  to  cover  it,  separate 
turns  should  be  made  for  the  purpose. 


652 


THE   KOLLKH    BAM)A(1E 


No.  43.     Spica  of  the  Thumb ;  a  One  Inch  Bandage. 

— The  area  covered  by  this  bandage  is  the  thumb,  including  the 
dorsal  and  palmar  surfaces  of  its  base,  and  the  circle  of  the  wrist. 
It.  is  useful  to  keep  a  dressing  in  place,  or  to  prevent  motion  in 
the  joints  of  the  thumb. 

The  bandage  is  fixed  by  a  circular  turn  at  the  wrist,  and  car- 
ried obliquely  over  the  back  of  the  thumb  to  the  distal  phalanx. 
The  thumb  is  then  covered  by  an  ascending  spiral  bandage,  and 
just  before  the  web  of  the  thumb  is  reached  this  is  changed  to  a 
figure  of  eight  bandage  around  the  thumb  and  wrist  (Fig.  372). 
The  first  figure  of  eight  turn  around  the  wrist  should  be  followed 
by  a  circular  turn  for  greater  security,  and  the  first  figure  of  eight 
turn  around  the  thumb  should  be  followed  by  a  circular  turn  to 
cover  the  triangular  gap  which  would  otherwise  be  left  bare.  Two 
additional  figure  of  eight  turns  complete  the  bandage.     The  cross- 


Fig.  372. — Spica  Bandage  of  the  Thumb,   Showing  Completion  of  the  First 
Figure  of  Eight  Turn. 


ings  of  the  figure  of  eight  turns  may  be  placed  more  posteriorly 
or  anteriorly,  according  to  the  portion  of  the  thumb  which  it  is 
desired   to  cover.      If  the  bandage  is  used  to  fix  the  joints  of 


SPIRAL  REVERSE   BANDAGE   OF   FINGER 


65; 


the   thumb,   it  is  well  to  keep  these  crossings  on  the  posterior 
surface. 

No.  44.  Spiral  Reverse  of  Finger  ;  a  One  Inch  Band- 
age.— The  area  covered  by  this  bandage  is  the  finger.  If  it  is 
desired  to  cover  the  end  of  the  finger,  this  bandage  should  be  com- 
bined with  the  recurrent  bandage  (No.  47).  The  bandage  is  use- 
ful to  keep  a  dressing  in  place,  or  to  prevent  motion  in  the  joints 


Fig.  373. — Spiral  Reverse  Bandage  of  the  Finger,  Showing  the  Second  Re- 
verse. The  middle  finger  of  the  other  hand  has  been  completely  bandaged  by 
the  same  method. 

of  the  finger.  The  finger  can  be  bandaged  by  a  simple  spiral,  but 
in  most  cases  a  better  fitting  bandage  is  obtained  by  using  the 
spiral  reverse,  or  figure  of  eight. 

The  bandage  is  anchored  by  a  circular  turn  around  the  ter- 
minal phalanx  of  the  finger,  and  an  ascending  spiral  started.  Each 
time,  as  the  bandage  is  carried  upward  over  the  back  of  the  finger, 
it  should  be  reversed  (Fig.  373).  When  the  base  of  the  finger  is 
reached  the  bandage  may  be  fastened,  or  it  may  be  carried  over 
the  back  of  the  hand  and  around  the  wrist  in  two  figure  of  eight 
turns. 


654 


THE   ROLLER    BANDAGE 


No.  45.  Figure  of  Eight  of  Finger  ;  a  One  Inch  Band- 
age.— The  area  covered  by  this  bandage  is  the  finger.  If  it  is 
desired  to  cover  the  end  of  the  finger  this  bandage  should  be  com- 
bined with  the  recurrent  (No.  47).  The  bandage  is  useful  to  keep 
a  dressing  in  place,  or  to  limit  motion  in  the  joints  of  the  finger. 

The  bandage  is  anchored  by  a  circular  turn  around  the  ter- 
minal phalanx  of  the  finger.  It  is  then  carried  obliquely  upward 
across  the  back  of  the  finger  to  about  the  base  of  the  second  pha- 
lanx, around  the  finger  at  this  level,  and  obliquely  downward 
nearly  to  the  starting-point  (Fig.  374),  making  a  figure  of  eight 
turn.  A  second  and  a  third  figure  of  eight  should  be  applied, 
each  one  nearer  the  hand  than  the  preceding.      The  lower  per- 


Fig.  374. — Figure  of  Eight  Bandage  of  Finger,  Showing  the  Completion  of 
the  First  Figure  of  Eight  Turn.  The  completed  bandage  of  the  ring  finger 
was  applied  by  the  same  method. 

manent  edge  of  each  turn  should  be  kept  taut;  the  upper,  loose 
edge  is  covered  in  by  a  subsequent  turn.  The  bandage  is  finished 
with  a  circular  turn  around  the  base  of  the  finger,  or  it  may  be 
carried  across  the  back  of  the  hand  and  around  the  wrist  in  figure 
of  eight  turns. 


THE   GAUNTLET   BANDAGE 


(\r>r> 


No.  46.  The  Gauntlet,  or  Figure  of  Eight  of  the 
Fingers  and  "Wrist ;  a  One  Inch  Bandage. — The  area  covered 
by  this  bandage  is  that  of  one  or  more  fingers,  a  corresponding 


Fig.  375. — The  Gauntlet  Bandage,  Showing  the  Completion  of  the  Bandage 
of  One  Finger.  Note  that  the  bandage  is  carried  across  the  dorsum  of  the 
wrist  from  the  ulnar  to  the  radial  side. 


portion  of  the  back  of  the  hand,  and  the  circle  of  the  wrist.     The 
bandage  is  useful  to  keep  dressings  in  place  on  the  fingers. 

The  bandage  is  anchored  by  two  circular  turns  around  the 
wrist,  crossing  the  dorsum  of  the  wrist  from  the  ulnar  to  the 
radial  side.  It  is  then  carried  across  the  back  of  the  hand,  and 
spirally  around  the  finger  to  its  tip.  If  the  end  of  the  finger  is 
to  be  covered,  the  recurrent  turns  should  be  next  made  (]STo.  47). 
If  the  end  of  the  finger  is  not  to  be  covered,  the  finger  itself  is 
bandaged  with  spiral  reverse  or  figure  of  eight  turns  from  the  tip 
of  the  finger  up  to  the  hand.  A  figure  of  eight  turn  is  next  car- 
ried across  the  back  of  the  hand  and  around  the  wrist  (Fig.  375). 
This  may  be  repeated,  if  necessary,  and  an  additional  circular  turn 
applied  around  the  wrist  before  the  bandage  is  carried  to  the  next 
finger.     In  this  manner  one  or  more  of  the  fingers  and  thumb  are 


656 


THE    ROLLER    BAM>A<;i: 


bandaged,  while  the  palm  is  left  free;  hence  the  name  "  gauntlet" 
has  been  applied  to  the  bandage. 

No.  47.  The  Recurrent  of  the  Finger  ;  a  One  and  One- 
Half  Inch.  Bandage. — The  area  covered  by  this  bandage  is  the 
finger,  including  its  tip,  a  part  of  the  hack  of  the  hand,  and  a 
circle  of  the  wrist.  This  bandage  is  \\^>i\  to  keep  a  dressing  in 
place  over  the  finger.  Frequently  two  or  more  fingers  are  band- 
aged  together. 

The  bandage  is  started  on  the  dorsum  of  the  finger  near  its 
base,  and  is  carried  directly  over  the  end  of  the  finger,  and  nearly 
to  its  base  on  the  palmar  surface.  It  is  then  carried  over  the  end 
of  the  finger  hack  to  the  starting-point,  overlapping  the  previous 
turn  by  about  a  third  of  its  width.  It  is  again  carried  over  the 
end  of  the  finger  to  the  palmar  surface,  overlapping  the  previous 


Fig.  37G  — Recurrent  Bandage  of  the  Finger,  Showing  Its  Application  to 
the  Forefinger.  One  half  of  the  lateral  excess  of  the  bandage  at  the  tip  of  the 
finger  has  been  caught  by  the  first  figure  of  eight  turn. 

turn,  in  the  opposite  direction,  by  two-thirds  of  its  width.  Usually 
these  three  recurrent  turns  are  sufficient  to  leave  a  lateral  excess 
of  bandage  at  the  tip  of  the  finger.     This  excess  is  smoothly  band- 


ASCENDING  SPICA   BANDAGE   OF   ONE   GROIN 


657 


aged  in  with  figure  of  eight  or  spiral  reverse  turns  (Figs.  370 
and  377),  according  to  the  directions  given  for  bandages  ISTos.  44 
and  45.     When  the  base  of  the  finger  is  reached,  two  figure  of 


Fig.  377. — Recurrent  Bandage  of  the  Finger  at  a  Later  Stage. 

eight  turns  are  carried  across  the  back  of  the  hand  and  around 
the  wrist. 


BANDAGES  OF  THE  LOWER  EXTREMITY 

No.  48.  Ascending  Spica  of  One  Groin  ;  a  Three  Inch 
Bandage. — The  area  covered  by  this  bandage  is  a  circle  of  the 
trunk,  the  groin,  the  corresponding  lower  quadrant  of  the  abdo- 
men, and  the  upper  portion  of  the  thigh.  This  bandage  is  useful 
to  keep  a  dressing  in  place  or  to  make  pressure  in  the  groin. 

The  bandage  is  anchored  by  two  circular  turns  around  the 
upper  part  of  the  thigh,  crossing  the  front  of  the  thigh  from  within 
outward.  It  is  then  carried  obliquely  upward  and  outward  to  the 
crest  of  the  ilium  on  the  same  side,  once  around  the  body,  and 
across  the  back  to  the  crest  of  the  ilium  on  the  opposite  side.  From 
there  it  is  carried  across  the  abdomen,  as  low  down  as  the  symphy- 


65$ 


THE    KOLLE.5    BANDAGE 


ms  pubis,  and  back  to  the  starting-poiiil  (Fig.  378).  It  is  car- 
ried circularly  around  the  thigh  to  cover  the  triangular  gap  which 
would  otherwise  be  left  bare.  Additional  figure  of  eight  turns  are 
then  applied,  each  of  which  overlaps  the  previous  figure  of  eight 
turn  upward  by  one-third  the  width  of  the  bandage.  The  line  of 
intersection  of  these  figure  of  eight  turns  should  be  a  vertical  one, 
and  should  cross  the  point  where  the  greatest  amount  of  pressure 
is  needed.     If  the  final  descending  turns  of  the  figure  of  eight  tend 


Fig.  378. — Ascending  Spica  Bandage  of  one  Groin,  Showing  the  Completion  of 
the  First  Figure  of  Eight  Turn.  .  Note  that  both  the  ascending  and  descend- 
ing portions  of  the  figure  of  eight  are  low  down.  Subsequent  turns  will  overlap 
this  one  upward. 


to  slip  downward,  they  should  each  be  pinned  where  they  cross  the 
vertical  line  referred  to  (Fig.  379). 

No.  49.  Descending  Spica  of  One  Groin;  a  Three 
Inch  Bandage. — The  area  covered  by  this  bandage  and  its  uses 
are  the  same  as  those  of  the  ascending  spica  of  one  groin  (No.  48). 

The  bandage  is  anchored  around  the  iliac  crest,  and  carried 


ASCENDING  SPICA  BANDAGE  OF   BOTH    GROINS  659 

obliquely  downward  across  the  upper  part  of  the  groin.  It  is  then 
carried  around  the  thigh  and  obliquely  upward  across  the  upper 
part  of  the  groin,  and  once  more  around  the  body.     Succeeding 


Fig.  379. — Ascending  Spica  Bandage  of  One  Groin,  Ready  for  Fastening. 

figure  of  eight  turns  are  made  to  cross  the  groin,  each  a  little  lower 
down  than  the  preceding  one.  In  other  words,  the  application  of 
this  bandage  is  the  reverse  of  the  application  of  the  ascending  spica 
of  the  groin  described  above. 

No.  50.  Ascending  Spica  of  Both  Groins;  a  Three 
Inch  Bandage. — The  area  covered  by  this  bandage  is  a  circle 
around  the  pelvis,  the  lower  portion  of  the  abdomen,  both  groins, 
and  the  upper  portion  of  both  thighs.  This  bandage  is  useful  to 
keep  dressings  in  place,  or  to  make  pressure  in  both  groins. 

The  bandage  is  anchored  by  two  circular  turns  around  the 

upper  part  of  the  left  thigh,  crossing  the  front  of  the  thigh  from 

within  outward.     It  is  then  carried  obliquely  upward  and  outward 

to  the  crest  of  the  ilium  on  the  same  side,  once  around  the  body, 
44 


661) 


THE   ROLLER    BANDAGE 


and  across  the  back  to  the  crest  of  the  right  ilium.  From  there 
it  is  carried  across  the  righl  groin,  one  and  one-half  limes  around 
the  right  thigh,  and  upward  jusl  above  the  symphysis  pubis  to  the 
crest  of  the  left  ilium.  It  is  nexl  carried  across  the  back,  and 
above  the  crest  of  the  right  ilium,  over  the  symphysis  pubis,  and 


Fig.   380.— Ascending  Spica   Bandage  of  Both  Groins,   Showing  the   Double 
Figure  of  Eight  Turn  Almost  Completed. 

downward  across  the  left  groin  (Fig.  380).  These  various  turns 
are  repeated  three  or  four  times  until  the  bandage  is  complete. 
Each  figure  of  eight  overlaps  the  previous  one  upward  for  a  dis- 
tance equal  to  one-third  of  the  width  of  the  bandage.  It  will  be 
noted  that  the  bandage  is  carried  obliquely  upward  across  one 
groin  from  within  outward,  and  obliquely  downward  across  the 
other  groin,  from  without  inward.  It  is  necessary  to  carry  the 
bandage  once  around  the  trunk  between  these  two  turns,  as  other- 
wise the  bandage  w7ill  slip  down  the  back.  When  the  bandage  is 
carried  upward  across  the  groin  from  without  inward,  it  makes 
almost  a  complete  circle  of  the  trunk  before  it  is  carried  down- 


ASCENDING  SPICA   BANDAGE   OP  THE    BUTTOCK 


661 


ward  and  outward  across  the  other  groin;  hence,  it  is  not  necessary 
to  carry  the  bandage  once  around  the  trunk  between  these  two 
turns,  as  it  shows  no  tendency  to  slip  down. 

No.  51.  Descending  Spica  of  Both.  Groins;  a  Three 
Inch  Bandage. — The  area  covered  by  the  descending  spica  of 
both  groins  and  its  uses  are  similar  to  those  of  the  ascending 
spica  of  both  groins  (No.  50). 

The  bandage  is  anchored  by  a  circular  turn  around  the  iliac 
crests  and  carried  downward  in  figure  of  eight  turns  alternately 
over  the  right  and  left  groins,  the  lower  figure  of  eight  turn  be- 
ing combined  with  circular  turns  around  the  thighs.  (Compare 
No.  50.) 

No.  52.  Ascending  Spica  of  the  Buttock ;  a  Three 
Inch  Bandage. — The  area  covered  by  this  bandage  is  the  buttock, 
a  circle  around  the  trunk,  and  one  around  the  thigh.  It  is  useful 
to  keep  a  dressing  in  place,  or  to  make  pressure  upon  the  buttock. 


Pig.  381. — Ascending  Spica  Bandage  of  the  Buttock,   Showing  the   Comple- 
tion of  the  First  Figure  of  Eight  Turn. 


(162 


Till:    ROI.LEK    BANDAGE 


The  bandage  is  anchored  by  two  circular  (urns  around  the 
upper  part  of  the  thigh,  crossing  the  hack  of  the  thigh  from  within 
•  mi  ward.  It  is  then  carried  obliquely  across  the  buttock  to  the 
loin  at  the  level  of  the  crest  of  the  ilium.  It  is  then  carried  one 
and  one-half  times  around  the  body,  and  obliquely  downward 
across  the  buttock  (  Fig.  381).  Next,  a  circular  turn  is  made 
around  the  thigh,  slightly  above  the  preceding  one,  and  a  figure 
of  eight  turn  around  the  body  overlapping  the  previous  figure  of 
eighl  turn  upward  by  one-third  the  width  of  the  bandage1.  This  is 
repeated  until  the  buttock  has  been  covered  in  (Fig.  382).  The 
points  of  intersection  of  these  figure  of  eight  turns  should  all  fall 
in  a  vertical  line,  and  that  vertical  line  should  be  situated  where  the 
greatest  amount  of  pressure  is  required.  This  may  be  as  far 
forward  as  the  great  trochanter,  or  nearly  back  to  the  median  line. 


Fig.  382. — Ascexdixg  Spica  Bandage  of  the  Buttock  Completed. 

Descending  Spica  of  the  Buttock. — The  descending  spica  of  the 
buttock  is  similar  to  the  above  excepting  that  it  is  anchored  around 
the  waist  and  the  figure  of  eight  turns  progress  downward. 


CROSSED   PERINEAL    BANDAGE 


<><;:; 


No.  53.     Crossed  Perineal ;   a  Three  Inch  Bandage. — 

The  area  covered  by  this  bandage  is  the  perineum,  the  upper  por- 
tion of  both  thighs,  and  the  lower  portion  of  the  trunk.  It  is 
useful  to  make  pressure  upon  the  perineum,  or  to  hold  a  dressing 
in  place. 

The  bandage  is  anchored  by  a  circular  turn  around  the  pelvis 
just  beneath  the  crest  of  the  ilia,  crossing  the  back  from  the  left 


Fig.   383.- 


-Crossed    Bandage    of    Perineum;  First  Figure  of  Eight   Turn  is 
Around  the  Left  Thigh. 


side  to  the  right.  It  is  then  carried  across  the  right  groin,  diag- 
onally backward  across  the  perineum,  across  the  back  of  the  left 
thigh,  and  upward  over  the  left  trochanter,  and  across  the  abdo- 
men from  left  to  right  (Fig.  383).  It  is  then  carried  around 
the  pelvis,  crossing  the  back  this  time  from  right  to  left,  and 
obliquely  downward  across  the  left  groin,  across  the  perineum, 
around  the  back  of  the  right  thigh  and  above  the  right  trochanter, 
until  the  circle  of  the  pelvis  is  again  reached  (Fig.  384).  These 
turns  may  be  repeated  as  many  times  as  are  necessary. 


664 


THE   HOLLER    BAXDAOE 


It  "will  be  observed  that  this  bandage  is  made  up  of  a  series 
of  figures  of  eighl   around  one  thigh  and  the  pelvis,  alternating 

with  figures  of  eight   around  the  other  thigh  and  pelvis;  and  that 


Fig.  384. — Crossed  Bandage  of  Perineum;  Second  Figure  of    Eight  Turn  is 
Around  the  Right  Thigh. 


the  direction  in  which  the  bandage  is  carried  around  the  pelvis  is 
changed  each  time  the  bandage  goes  around  a  thigh. 

No.  54.  Spiral  Reverse  of  Thigh  ;  a  Three  Inch  Band- 
age.— The  area  covered  by  this  bandage  is  the  thigh.  In  most 
persons  the  circumference  of  the  thigh  increases  upward,  so  that 
a  simple  spiral  will  not  fit  accurately,  and  even  the  spiral  reverse, 
though  accurately  applied,  will  not  long  remain  in  position  when 
the  patient  is  walking  about.  For  this  reason  it  is  better  to  com- 
bine this  bandage  in  most  ambulant  cases  with  the  ascending  spica 
of  the  groin  (iSTo.  48).  This  bandage  is  used  to  make  pressure 
upon  the  thigh,  or  to  hold  a  dressing  in  place. 

The  bandage  is  anchored  by  a  circular  turn  around  the  thigh 
just  above  the  knee,  and  is  carried  spirally  upward,  each  turn 


Fig.  3S5. — Spiral  Reverse  Bandage  of  Thigh,  Showing  the  Introduction  op 

the  First  Reverse. 


Fig.  386. — Spiral  Reverse  Bandage  of  Thigh  Completed. 

665 


666 


tin;  nm.i.Ki;   uaxdage 


overlapping  the  preceding  one  by  one-third  of  its  width.  As  soon 
as  it  becomes  evident  that  the  upper  edge  of  the  bandage  is  tighter 
than  the  lower,  the  bandage  should  he  reversed  every  time  it  is 
brought  to  the  front  of  the  thigh  (Fig.  385).  The  bandage  may- 
be completed  by  a  circular  turn  just  below  the  groin  (Fig.  3SG),  or 
it  may  be  continued  in  the  form  of  a  spica.  In  either  case,  slipping 
of  the  individual  turns  of  the  bandage  may  be  prevented  by  two  or 
three  vertical  strips  of  adhesive  plaster,  or  by  two  or  three  vertical 
rows  of  stitches.  This  precaution  is  recommended  in  the  case  of 
all  stout  persons  who  are  walking  about,  as  otherwise  the  physician 
is  likely  to  be  embarrassed  by  the  information  that  the  bandage 
slipped  down  to  the  shoe  within  half  an  hour. 

No.  55.  Concentric  Figure  of  Eight  of  Knee,  or  Tes- 
tudo  In  versa ;  a  Two  and  One-Half  Inch  Bandage. — The 
area  covered  by  this  bandage  is  the  region  of  the  knee-joint.     It 


Fig.  387. — Concentric  Figure  of  Eight  Bandage  of  Knee.     All  the  spiral  turns  are 
in  place,  and  the  first  figure  of  eight  is  about  to  be  completed. 

may  be  applied  when  the  joint  is  extended  or  flexed.     It  is  used 
to  keep  a  dressing  in  place,  or  to  make  pressure  upon  the  joint. 


ECCENTRIC   FIGURE   OF   EIGHT   BANDAGE  OF  KNEE        007 

The  bandage  is  fixed  by  a  circular  turn  around  the  upper  part 
of  the  leg,  and  is  carried  spirally  upward  until  it  almost  reaches 
the  patella.  It  is  then  carried  obliquely  across  the  posterior  sur- 
face of  the  joint,  and  across  the  front  of  the  thigh,  high  enough 
up  to  lie  above  the  extreme  upper  limit  of  the  synovial  membrane 
of  the  joint.     It  is  then  carried  around  the  thigh  in  one  or  more 


Fig.  388. — Concentric  Figure  of  Eight  Bandage  of  Knee,  Complete. 

descending  spiral  turns,  until  it  reaches  nearly  to  the  patella 
(Fig.  387).  A  series  of  figure  of  eight  turns  is  next  applied,  each 
one  nearer  to  the  center  of  the  patella,  until  the  whole  surface  is 
covered.  A  circular  turn  over  the  patella  completes  the  bandage. 
The  crossings  of  these  figure  of  eight  turns  are  at  the  back  of  the 
leg,  so. that  they  do  not  show  when  the  bandage  is  viewed  from 
in  front  (Fig.  388). 

No.  56.  Eccentric  Figure  of  Eight  of  Knee,  or  Tes- 
tudo  Reversa;  a  Two  and  One-Half  Inch  Bandage. — The 
area  covered  by  this  bandage  is  the  region  of  the  knee-joint.     It 


668 


THE   ROLLER    BANDAGE 


is  applied  when  the  joint  is  cither  extended  or  flexed.  1 1  is  used 
to  keep  a  dressing' in  place,  or  to  make  pressure  upon  the  joint, 
or  to  limit  its  motion. 

The  bandage  is  fixed  by  two  circular  turns  directly  around  the 
knee-joint.  As  the  third  turn  reaches  the  patella,  it  is  carried 
slightly  above  the  second  turn,  but  exactly  overlies  it  at  the  back 


Fig.  389. — Eccentric  Figure  of  Eight  Bandage  of  the  Knee,  Completed. 


of  the  knee.  The  fourth  turn  is  carried  slightly  below  the  second 
at  the  patella,  but  crosses  it  at  the  median  line  behind.  This 
process  is  repeated,  each  figure  of  eight  turn  being  farther  and 
farther  from  the  patella,  until  the  joint  is  covered  (Fig.  389).  It 
will  be  found  of  advantage  to  interpose  a  circular  turn  between 
each  figure  of  eight  turn,  as  the  outer  limit  of  the  joint  is  ap- 
proached, carrying  these  circular  turns  alternately  around  the  leg 
and  around  the  thigh. 

No.  57.  Figure  of  Eight  of  Both  Knees ;  a  Two  and 
One-Half  Inch  Bandage. — The  area  covered  by  this  bandage  is 
that  of  both  knees.     It  is  applied  when  the  joints  are  extended, 


FIGURE   OF   EIGHT    BANDAGE   OF   LEG 


669 


and  is  used  to  prevent  flexion  of  the  knees  and  abduction  of  the 
thighs;  for  example,  after  perineorrhaphy. 

A  thick  compress  is  laid  between  the  knees,  and  bandaged  to 
one  of  them  by  a  few  circular  turns  around  the  leg  and  thigh. 
This  anchors  the  bandage.  It  is  then  carried  across  the  front  of 
both  knees,  and  spirally  upward  arojund  both  thighs  to  a  short 
distance  above  the  knees,  and^  downward  across  the  front  of  the 


Fig.  390, — Figure  of  Eight  Bandage  of  Both  Knees  Completed. 


knees  to  the  calves  of  the  legs.  From  this  lower  limit  the  bandage 
is  carried  upward  with  spiral  and  figure  of  eight  turns  sufficient 
in  number  to  entirely  cover  the  knees  (Fig.  390).  Two  vertical 
strips  of  adhesive  plaster  or  two  vertical  rows  of  stitching  will  add 
to  the  stability  of  this  bandage. 

No.  58.     Figure  of  Eight  of  Leg ;  a  Two  and  One-Half 
Inch  Bandage. — The  area  covered  by  this  bandage  is  the  leg 


670 


THE    ROLLER    1UXDAGE 


from  the  ankle  to  the  knee.     It  is  used  to  hold  a  dressing  in  place. 
If  there  is  a  tendency  for  the  leg  to  swell,  this  bandage  should  be 

combined  with  the  figure  of  eight 
of  the  ankle  (No.  60).  This  com- 
bination  is  the  usual  bandage  for 
ulcer  of  the  leg,  and  is  described 
in  detail  as  No.  61. 

The  bandage  is  anchored  by  a 
circular  turn  above  the  ankle,  and 
is  carried  spirally  upward  until 
the  lower  margin  becomes  full,  as 
it  usually  does  after  three  spiral 
turns.  Figure  of  eight  turns  are 
then  made,  each  one  reaching 
above  the  calf,  and  each  one  a  lit- 
tle higher  on  the  leg  than  its  prede- 
cessor. The  first  figure  of  eight 
turn  should  be  carried  one  and 
one-half  times  around  the  calf  be- 
fore it  is  brought  obliquely  down- 
ward (Fig.  301).  This  will  avoid 
any  risk  of  its  slipping.  The  in- 
tersections of  the  figure  of  eight 
turns  should  be  properly  placed 
in  the  median  line.  The  bandage 
is  completed  by  a  circular  turn 
around  the  calf.  Its  appearance 
is  the  same  as  that  of  No.  61,  except  that  the  ankle  and  foot  are 
not  covered   (see  Fig.  305). 

No.  59.  Spiral  Reverse  of  Leg  ;  a  Two  and  One-Half 
Inch  Bandage. — The  area  covered  by  this  bandage  is  the  leg 
from  above  the  ankle  to  below  the  knee.  It  is  used  to  hold  a  dress- 
ing in  place  and  to  reduce  or  prevent  swelling  of  the  leg.  When 
used  for  the  latter  purpose,  it  should  be  combined  with  No.  60. 

The  bandage  is  anchored  by  a  circular  turn  just  above  the 
malleoli,  and  is  carried  spirally  upward,  each  turn  overlapping 
the  previous  one  by  one-third  of  its  width.  Except  in  very  thin 
persons,  it  is  necessary  to  begin  reverses  almost  immediately. 
These  should  be  made  in  the  median  line  of  the  leg  anteriorly 


Fig.  391. — Figure  of  Eight  Band- 
age of  the  Leg,  Showing  the 
First  Figure  of  Eight  Turn. 
Note  that  the  bandage  is  carried 
one  and  one-half  times  around 
the  leg  above  the  calf. 


FIGURE   OF   EIGHT   BANDAGE   OF    ANKLE  671 

(Fig.  392).     Just  before  the  maximum  diameter  of  the  calf  is 
reached  the  reverses  are  discontinued,  and  the  bandage  is  com- 


Fig.  392.— Spiral  Reverse  Bandage  of  the  Leg,  Showing  Introduction  of  Re- 
verses Placed  Exactly  in  the  Median  Line  of  the  Leg. 


pleted  by  a  simple  spiral.  The  bandage  should  not  extend  high 
enough  to  interfere  with  flexion  at  the  knee-joint. 

"No.  60.  Figure  of  Eight  of  Ankle;  a  Two  Inch 
Bandage. — The  area  covered  by  this  bandage  is  a  circle  around 
the  foot,  the  anterior  portion  of  the  ankle,  and  a  circle  of  the  leg 
immediately  above  it.  It  is  used  to  keep  a  dressing  in  place,  or  to 
make  pressure  upon  the  ankle-joint,  or  to  limit  its  motion.  It  is 
often,  combined  with  the  spiral  reverse  of  the  leg  (!No.  59),  and 
forms  a  part  of  the  figure  of  eight  of  the  foot  and  leg  (ISTo.  61). 

The  bandage  is  fixed  by  a  circular  turn  around  the  leg  just 
above  the  malleoli.  It  is  then  carried  obliquely  downward  over 
the  anterior  surface  of  the  ankle  and  the  dorsum  of  the  foot,  and 
around  the  ball  of  the  foot,  and  back  to  the  starting-point  (Fig. 
393).     A  second  time  the  bandage  is  carried  around  the  foot, 


G72 


THE   ROLLER    BANDAGE 


and  then  two  or  throe  ligure  of  eight  turns  arc  applied,  each 
parallel  to  the  preceding  one,  and  slightly  above  it.  A  circular 
Turn  amund  the  ankle  completes  the  bandage. 


Fig.  393. — Figure  of  Eight  Bandage  of  the  Ankle,  Showing  the  Completion 
of  the  First  Figure  of  Eight  Turn. 

No.  6 1 .  Figure  of  Eight  of  Foot  and  Leg  ;  a  Two 
and  One-Half  Inch  Bandage. — The  area  covered  by  this  band- 
age is  the  whole  of  the  foot  and  leg,  with  the  exception  of  the 
toes  and  the  heel.  It  is  the  usual  bandage  employed  for  ulcers 
of  the  leg,  and  for  other  lesions  below  the  knee  in  which  a  com- 
plete bandage  is  required  in  order  to  prevent  swelling.  If  the 
heel  is  covered,  the  foot  is  much  more  clumsy,  and  as  the  heel 
does  not  swell  much  even  in  cases  of  general  edema  of  the  leg 
and  foot,  it  is  usually  better  not  to  include  it  in  the  bandage. 

The  bandage  is  anchored  by  a  circular  turn  carried  around 
the  base  of  the  toes  from  the  inner  to  the  outer  margin  of  the 
foot  Two  or  possibly  three  spiral  turns  are  made  around  the 
foot,  and  then  the  bandage  is  carried  around  the  ankle  just  above 


FIGURE   OP    EIGHT    BANDAGE   OF   FOOT   AND   LEG         673 


the  heel,  and  brought 
back  over  the  dorsum 
of  the  foot,  making  a 
figure  of  eight  turn 
(Fig.  394).  Another 
circular  turn  is  made 
around  the  foot,  and  a 
second  figure  of  eight 
turn  around  the  ankle, 
higher  than  the  previ- 
ous one  by  one-third  of 
the  width  of  the  band- 
age.    If  space  permits, 


Fig.  395. — Figure  of  Eight  Bandage  of  the  Foot 
and  Leg,  Showing  the  Completion  of  the 
First  Figure  of  Eight  Turn  of  the  Leg. 


Fig.  394. — Figure  of  Eight 
Bandage  of  the  Foot  and 
Leg,  Shoeing  the  Band- 
age of  the  Foot  Nearly 
Completed. 

a  third  figure  of  eight 
turn  may  be  applied. 
ISText  the  bandage  is 
carried  spirally  up- 
ward from  the  ankle, 
until  the  increasing 
size  of  the  leg  makes 
the  lower  edge  of  the 
bandage  loose.  It  is 
then  carried  obliquely 
upward,  across  the 
front  of  the  leg,   and 


r.7l 


l'lll.    liol.LKli    BANDAGE 


then  once  around  the  leg  jusl  below  the  knee.  As  the  leg  tapers 
from  the  calf  toward  the  knee,  the  slack  in  the  lower  edge  of  the 
bandage  is  taken  up,  not  only  by  the  change  in  direction  of  the 
bandage,  bnt  also  by  the  change  in  the  shape  of  the  leg.  The  band- 
age is  next  brought  down  across  the  front  of  the  leg  (Fig.  395), 
and  a  circular  turn  is  made;  and  then  a  figure  of  eight  turn  which 
overlaps  ihe  preceding  one  by  one-third  the  width  of  the  bandage 
below,  but  which  exactly  overlies  it  as  it  passes  around  the  leg 


Fig.  396. — Figure  of  Eight  Bandage  of  the  Foot  and  Leg  Completed. 

below  the  knee.  A  third  figure  of  eight  turn,  with  a  circular  turn 
at  its  upper  and  lower  end,  is  also  applied.  After  that  the  bandage 
is  completed  solely  by  figure  of  eight  turns,  and  finished  with  a 
circular  turn  around  the  upper  part  of  the  leg.  The  upper  margin 
of  the  bandage  must  not  be  high  enough  to  interfere  with  flexion  of 
the  knee-joint  (Fig.  396). 


ECCENTRIC   FIGURE   OF   EIGHT   BANDAGE   GF   HEEL       675 

A  bandage  of  this  character,  properly  applied,  will  remain  in 
place  indefinitely,  and  will  give  a  firm,  even  pressure  over  the 
whole  surface  of  the  leg. 

No.  62.  Eccentric  Figure  of  Eight  of  Heel,  or  Tes- 
tudo  Reversa ;  a  Two  Inch  Bandage. — The  area  covered 
by  this  bandage  is  the  whole  surface  of  the  heel  and  the  ankle. 


Fig.  397. — Eccentric  Bandage  of  the  Heel,  Showing  the  Completion  of  the 

Fourth  Turn. 

It  is  used  to  keep  a  dressing  in  place  on  the  heel  or  to  limit  the 

motion  of  the  ankle.     For  both  purposes  it  is  often  combined 

with  other  bandages  of  the  foot  and  leg. 

The  bandage  is  anchored  by  a  circular  turn  from  the  anterior 

surface  of  the  ankle  directly  around  the  heel.      A  second  turn 

extends  somewhat  beyond  the  first  one  upward,  where  it  passes 

over  the  heel,  but  crosses  the  first  turn  in  the  median  line  in 

front.     The  third  turn  extends  beyond  the  first  one  downward  at 

the  heel,  but  crosses  it  in  the  median  line  in  front.     The  fourth 

turn  (Fig.  397)  -reaches  still  farther  upward  at  the  heel.     These 

diverging  figure  of  eight  turns  are  continued  until  the  whole  heel 

is  covered.     Care  must  be  taken  not  to  pull  too  tightly  the  turns 

which  cover  the  under  surface  of  the  heel,  lest  they  be  dragged 
45 


f>7fi 


THE    KOI.LKK    BANDAGE 


forward  thereby.  If  this  bandage  is  combined  with  a  bandage 
of  the  foot  and  leg  (Xo.  61),  or  with  the  figure  of  eight  of  the 
ankle  (Xo.  00),  it  should  be  the  first  one  applied,  so  that  the 
other  handage  shall   partly  cover  it  and  protect  its  weak  parts. 

No.  63.  Modified  Eccentric  Figure  of  Eight  of  Heel; 
a  Two  Inch  Bandage. — The  area  covered  by  this  bandage  is 
the   whole    surface   of   the   heel   and   the   ankle.      It  is   used   to 


Fig.  398. — Modified  Eccentric  Figure  of  Eight  Bandage  of  the  Heel,  Show- 
ing the  Completion  of  the  First  Lateral  Binding  Turn  of  the  Heel. 


keep  a  dressing  in  place  on  the  heel  or  to  limit  the  motion  of 
the  ankle.  It  is  a  more  stable  bandage  than  Xo.  02,  and  is  less 
clumsy.  It  is  often  combined  with  other  bandages  of  the  foot 
and  leg. 

The  bandage  is  started  on  the  front  of  the  ankle  and  is  an- 
chored by  a  circular  turn  directly  around  the  heel.  A  second 
turn  extends  farther  downward  than  the  first  turn,  as  it  passes 
over  the  heel,  but  crosses  the  first  turn  in  the  median  line  in 
front.  The  third  turn  extends  farther  upward  than  the  first  on 
the  heel,  but  crosses  it  in  the  median  line  in  front.  A  fourth 
turn  is  applied,  divergent  downward.  Thus  far  this  bandage  is 
exactly  like  Xo.  02.     A  fifth  turn  is  started  more  divergent  than 


SPICA    RANDACiE   OP    FOOT 


077 


the  others,  but  when  the  bandage  passes  the  posterior  median  Line, 
above  or  below  the  heel,  as  the  case  may  be,  it  is  carried  along  the 
side  of  the  heel  and  brought  back  to  the  starting-point  without 
having  encircled  the  ankle  (Fig.  308).  A  similar  loop  is  made 
around  the  heel  from  the  other  side,  and  one  figure  of  eight  turn 
of  the  foot  and  leg  completes  the  bandage  unless  it  is  desired  to 
add  to  it  one  of  the  other  bandages  of  the  foot  and  leg.  These 
side  turns  hold  the  eccentric  figure  of  eight  turns  firmly ;  further- 
more they  aid  in  the  covering  of  the  heel,  so  that  far  less  bandage 
is  employed.  These  are  points  of  superiority  which  have  well- 
nigh  rendered  obsolete  the  eccentric  figure  of  eight  bandage  of 
the  heel  (Eo.  62). 

No.  64.     Spica  of  Foot;  a  Two   Inch  Bandage. — The 
area  covered  by  this  bandage  is  the  whole  surface  of  the  foot 


Fig.  399. — Spica  Bandage  of  Foot,  Showing  the  Completion  of  the  First  Figure 
of  Eight  Turn  Around  the  Heel. 


and  ankle,  with  the  exception  of  the  under  surface  of  the  heel.     It 
is  useful  to  keep  dressings  in  place. 

The  bandage  is  anchored  by  a  circular  turn  around  the  ankle. 
It  is  then  brought  over  the  dorsum  of  the  foot  and  carried  once 
around  the  base  of  the  toes.     The  instep  is  covered  in  by  two 


678 


THE   ROLLER    BANDAGE 


or  three  spiral  or  spiral  reverse  I  urns.  The  bandage  is  then  car- 
ried across  the  back  of  the  heel,  over  the  dorsum  of  the  foot  to 
the  base  of  the  toes  (Fig.  399),  making  a  figure  of  eight  turn. 
Two  or  three  additional  figure  of  eight  turns  are  applied,  each 
one  higher  on  the  ankle,  and  farther  hack  on  the  foot.  The  hand- 
age  is  completed  by  a  circular  turn  above  the  ankle. 

No.  65.  Circular,  or  Spiral  of  Toe  ;  a  One  Inch  Band- 
age.— The  area  covered  by  this  bandage  is  the  surface  of  any 
toe,  with  the  exception  of  its  extremity.  It  is  used  to  render 
the  joints  immobile  or  to  keep  a  dressing  in  place.  If  it  is  de- 
sired to  cover  the  end  of  one  or  more  toes,  the  recurrent  bandage 
should  be  employed.      (Compare  Xo.  47.) 

No.  66.  Spica  of  the  Great  Toe ;  a  One  Inch  Band- 
age. — The  area  covered  by  this  bandage  is  that  of  the  great  toe, 
excepting  its  tip,  and  a  portion  of  the  foot.  It  is  used  to  keep  a 
dressing  in  place  or  to  immobilize  this  toe. 


Fig.  400. 


-Spica  Bandage  of  the  Great  Toe,  Showing  the  Completion  of  the 
First  Figure  of  Eight  Turn. 


The  bandage  is  anchored  by  a  circular  turn  around  the  ball 
of  the  foot,  and  is  then  carried  over  the  dorsum  of  the  great  toe 
to  its  terminal  phalanx.     Two  spiral  turns  are  applied  to  the  toe, 


COMPLEX   SPICA   BANDAGE  UP   THE   GREAT   TOE 


079 


and  one  or  two  figure  of  eight  turns  around  the  base  of  the  toe 
and  ball  of  the  foot  (Fig.  400),  with  intervening  circular  turns 
around  the  ball  of  the  foot. 

No.  67.  Complex  Spica  of  the  Great  Toe ;  a  One 
Inch  Bandage.- — The  area  covered  by  this  bandage  is  that  of 
the  great  toe,  excepting  its  tip,  a  part  of  the  dorsal  and  plantar 
surfaces  of  the  foot,  and  a  circle  around  the  ankle.     Tt  is  used  to 


Fig.  401. — Complex  Spica  Bandage  of  the  Great  Toe,  Showing  the  Completion 
of  the  First  Complex  Figure  of  Eight  Turn. 


keep  a  dressing  in  place,  or  to  immobilize  the  great  toe.  It  is  a 
more  secure  bandage  than  No.  66,  especially  in  the  case  of  per- 
sons with  chubby  feet. 

The  bandage  is  anchored  by  a  circular  turn  around  the  ankle, 
and  is  then  brought  spirally  downward  around  the  foot,  crossing 
the  dorsum  from  the  inner  to  the  outer  side.  It  is  then  carried 
over  the  dorsum  of  the  great  toe  to  its  terminal  phalanx.  Two 
spiral  turns  are  applied  to  the  toe,  and  the  bandage  is  carried  from 
the  inner  side  of  the  base  of  the  toe  over  the  dorsum  of  the  foot, 
and  around  the  lower  portion  of  the  ankle  (Fig.  401).  As  it 
is  brought  back  to  the  toe  the  bandage  is  carried  once  around  the 
foot,  and  then  once  around  the  toe.     This  complex  figure  of  eight 


680  THE   ROLLER    BANDAGE 

turn,  with  a  single  up  loop  and  a  double  down  loop,  is  repeated 
once  or  twice  to  complete  the  bandage,  which  may  also  be  com- 
bined with  No.  66. 

No.  68.  Recurrent  Bandage  of  a  Stump;  a  Three 
Inch  Bandage,  More  or  Less. — The  area  covered  by  this  band- 
age is  that  of  an  amputation  stump,  together  with  a  circle  of  the 
trunk,  or  of  the  upper  portion  of  the  limb.  The  bandage  is  used 
to  keep  a  dressing  in  place  or  to  make  pressure  upon  the  stump. 
This  bandage  is  applied  in  accordance  with  the  principles  of  the 
recurrent  bandage  of  the  finger,  but  because  of  the  flabby  nature 
of  most  stumps  extra  precautions  are  necessary  to  make  the  band- 
age firm.  The  bandage  of  the  stump  following  amputation 
through  the  thigh  is  one  of  the  most  difficult  to  apply,  as  well  as 
one  of  the  most  important.      It  will  therefore  be  described. 

If  a  dressing  is  employed,  it  should  not  extend  so  far  up 
the  thigh  as  to  prevent  the  bandage  from  coming  in  contact  with 
the  skin  above  it.  The  bandage  is  started  on  the  anterior  surface 
of  the  thigh,  carried  directly  over  the  end  of  the  stump  and  up 
the  posterior  surface  of  the  thigh,  folded  directly  backward,  and 
carried  again  over  the  end  of  the  stump  to  the  starting-point. 
These  and  subsequent  loose  ends  of  the  bandage  must  be  held 
snugly  in  place  by  the  thumb  and  fingers  of  one  hand  while  the 
bandage  is  applied  with  the  other.  If  the  thickness  of  the  stump 
is  too  great  to  permit  this,  the  patient  or  an  assistant  must  hold 
these  ends  on  either  the  anterior  or  posterior  surface.  Addi- 
tional recurrent  turns  are  now  applied,  each  overlapping  the  pre- 
vious one  by  one-third  of  the  width  of  the  bandage.  When  the 
end  of  the  stump  has  been  covered  and  there  is  an  excess  of  band- 
age at  its  margins,  the  bandage  is  wound  around  the  stump  in 
the  form  of  a  figure  of  eight,  covering  this  excess  first  on  one 
margin  and  then  on  the  other.  (Compare  the  Recurrent  Bandage 
of  the  Finger,  No.  47.)  Next,  a  slowly  ascending  spiral  is  ap- 
plied, and  completed  at  the  upper  end  of  the  bandage  with  two 
or  three  circular  turns,  or  with  some  figure  of  eight  turns  around 
the  upper  portion  of  the  thigh  and  around  the  pelvis.  (Cf.  No. 
49. )  The  bandage  is  made  even  more  firm  by  four  vertical  strips 
of  adhesive  plaster  or  by  rows  of  stitching.  If  carefully  made 
such  a  bandage  can  be  removed,  and  if  necessary  reapplied  as 
one  piece. 


CHAPTEK    XXII 
SURGICAL  DRESSINGS 

TEXTILE   MATERIALS 

Cotton. — During  the  history  of  surgery  many  materials  have 
been  used  to  remove  the  blood  from  a  wound  during  operation, 
and  to  absorb  discharges  from  a  wound  during  its  repair.  Most 
of  these  have  now  only  a  historic  interest,  since  cotton  and  gauze 
woven  from  cotton  have  superseded  nearly  all  other  materials  for 
both  of  these  purposes. 

Cotton  in  its  raw  state  has  very  little  absorbent  power  be- 
cause of  the  oil  and  gum  with  which  its  fibers  are  covered.  When 
the  cotton  has  been  bleached  by  chemicals,  and  the  oil  extracted, 
its  absorbent  power  is  very  great.  This  fact,  together  with  its 
cheapness  and  lightness,  the  toughness  of  its  fiber,  and  its  ready 
sterilization  by  steam  or  dry  heat  make  it  almost  the  ideal  mate- 
rial for  surgical  dressings. 

Unbleached  Cotton. — This  is  cotton  in  its  natural  state,  freed 
from  dirt,  combed,  and  put  up  in  pound  rolls.  It  is  non-absorbent, 
and  has  a  greater  elasticity  than  the  absorbent  cotton.  It  is 
therefore  preferable  as  a  padding  for  splints,  and  to  diffuse  the 
pressure  of  a  non-elastic  bandage ;  for  example,  in  chronic  ulcer 
of  the  leg  (p.  525).  These  properties  also  render  it  superior  to 
absorbent  cotton  for  vaginal  tampons,  but  for  this  purpose  it  is 
not  so  good  as  lamb's  wool.  It  costs  about  thirty-five  cents  a 
pound,  as  supplied  by  the  dealers  in  surgical  dressings.  A  con- 
siderably cheaper  grade  is  sold  in  dry-goods  stores  under  the 
name  of  cotton  batting  for  eighteen  cents  a  pound.  This  usually 
contains  more  or  less  extraneous  material. 

Absorbent  Cotton. — Absorbent  cotton,  as  supplied  by  the  manu- 
facturers of  surgical  dressings,  is  freed  from  dirt,  gum,  and  oil, 
combed  and  sterilized,  and  so  wrapped  in  tissue-paper  that  with 

a  little  care  it  remains  aseptic  until  it  is  all  used.     It  is  furnished 

681 


682  SURGICAL   DRESSINGS 

in  packages  of  various  sizes,  from  a  half  ounce  to  one  pound, 
costing  thirty-five  cents  a  pound  in  pound  packages.  On  account 
of  its  lack  of  elasticity,  it  is  inferior  to  unbleached  cotton  as  a 
padding  for  splints,  etc. 

Dry  cotton  is  not  a  suitable  material  to  bring  into  contact  with 
a  wound  cither  during  operation  or  afterward.  In  the  former 
case  its  fibers  are  likely  to  stick  to  the  wound,  and  also  to  the 
fingers  of  the  operator.  In  the  latter  case,  if  the  discharge  is 
small,  it  is  likely  to  evaporate  and  seal  the  cotton  to  the  wound 
or  to  the  surrounding  skin  with  a  scab  which  is  difficult  of  re- 
moval. If  cotton  is  used  for  sponging,  during  an  operation,  balls 
of  suitable  size  should  first  be  saturated  with  saline  or  some  anti- 
septic solution,  and  then  squeezed  dry.  In  this  state  the  cotton 
will  not  stick  to  the  wound  nor  to  the  fingers,  and  will  soak  up 
the  blood  instantly.  Another  method  is  to  make  cotton  balls 
and  cover  each  with  a  layer  of  gauze.  If  these  are  to  be  used 
in  a  moist  state,  the  gauze  is  unnecessary ;  if  they  are  to  be  used 
dry,  they  are  inferior  to  the  usual  gauze  sponges,  and  the  sav- 
ing in  expense  is  insignificant.  They  are  therefore  not  to  be 
recommended. 

When  absorbent  cotton  is  used  as  a  dressing  for  wounds  dur- 
ing the  period  of  repair  it  should  be  separated  from  the  wound 
by  one  or  more  layers  of  gauze.  This  may  be  first  applied  to  the 
wound  and  a  layer  of  cotton  placed  over  it,  or  a  thin  pad  of  cot- 
ton may  be  wrapped  in  gauze  exactly  as  one  wraps  a  flat  package 
with  paper.  A  few  stitches  keep  the  gauze  in  position.  Such  a 
dressing,  known  as  a  combined  dressing,  is  of  regular  use  in  most 
hospitals  as  a  covering  for  wounds  from  which  a  free  discharge 
is  anticipated.  A  dressing  of  this  sort  applied  at  operation  should 
not  be  too  voluminous,  for  it  is  capable  of  absorbing  a  great 
amount  of  fluid.  The  writer  knows  of  one  instance  in  which  a 
patient  bled  to  death  into  such  a  dressing  before  the  blood  soaked 
through  the  dressing  sufficiently  to  be  noticed. 

Cheaper  grades  of  absorbent  cotton  of  varying  degrees  of  ex- 
cellence can  now  be  obtained  in  most  dry-goods  stores  at  prices 
ranging  from  twenty  to  thirty  cents.  One  should  not  trust  the 
sterility  of  such  material,  but  should  roll  it  into  loose  packages, 
covering  each  with  muslin,  and  sterilizing  them  thoroughly  before 
bringing  the  cotton  into  contact  with  a  fresh  wound. 


GAUZE  683 

Substitutes  for  Cotton. — Oakum,  cotton  waste,  wood  wool,  etc., 
are  preparations  made  of  refuse  hemp,  or  cotton  fibers  or  wood 
which  possess  a  considerable  power  of  absorption,  and  which  are 
suitable  for  dressing  wounds  with  chronic  discharge  if  rigid  econ- 
omy is  necessary.     They  cost  from  ten  to  twenty  cents  a  pound. 

Lamb's  Wool. — Lamb's  wool  has  great  elasticity,  does  not 
become  soggy  when  exposed  to  moisture,  and  absorbs  readily  oily 
substances  and  glycerids.  When  cleaned  and  sterilized  it  is  there- 
fore an  excellent  material  for  vaginal  tampons.  It  costs  about 
two  dollars  a  pound,  but  it  is  so  light  that  an  ounce  package  will 
make  ten  tampons  of  ordinary  size. 

Gauze. — Bleached  absorbent  gauze  is  the  most  important  item 
in  surgical  dressings.  The  firmness  of  the  material  varies  accord- 
ing to  the  number  of  threads  to  the  inch.  The  quality  should  be 
selected  according  to  the  purpose  for  which  it  is  desired.  Thus  a 
gauze  which  has  24  X  32  threads  to  the  square  inch  is  suitable 
for  sponges  or  for  dressings,  but  has  not  sufficient  firmness  to 
make  a  good  bandage.  On  the  other  hand,  a  gauze  with  40  X  44 
threads  to  the  square  inch,  used  for  bandages,  is  unnecessarily 
expensive  when  used  for  sponges  or  dressings.  It  is,  however, 
an  unwise  economy  to  select  for  sponges  and  dressings  a  gauze 
with  too  large  a  mesh.  Such  a  gauze  absorbs  so  little  that  an 
additional  quantity  is  required  in  every  case,  so  that  the  total 
expense  is  very  likely  increased. 

Gauze  suitable  for  sponges  and  dressings,  having  26  X  32 
threads  to  the  square  inch,  costs  at  the  present  time  from  four  to 
five  cents  a  yard,  by  the  piece  of  100  yards.  This  price  is  in- 
creased to  eight  or  even  ten  cents  a  yard  when  the  gauze  is  pur- 
chased in  small  pieces,  previously  sterilized  and  hermetically 
sealed. 

Gauze  for  bandages,  having  40  X  44  threads  to  the  square 
inch,  costs  from  five  to  seven  cents  a  yard,  by  the  piece  of  fifty 
yards. 

Gauze  Sponges. — A  square  yard  of  gauze  will  make  sixteen 
small  sponges.  If  larger  ones  are  desired,  the  yard  may  be  cut 
into  four  strips,  and  each  strip  cut  into  three  pieces,  thereby  giving 
twelve  sponges  to  the  yard.  A  more  convenient  method  is  to  take 
the  piece  of  gauze  as  it  comes  folded  back  and  forth  in  the  yard 
lengths,  and  to  cut  twelve  or  fifteen  thicknesses  into  nine  inch 


684 


SURGICAL   DRESS  L\  ( iS 


squares.  Half  of  these  squares  lying  along  the  natural  folds  of 
gauze  will  then  be  of  double  thickness,  and  sponges  made  from 
them  will  be  twice  as  large  as  those  made  from  the  single  squares. 
This  gives  eight  thick  sponges  and  sixteen  thin  sponges  to  every 
two  yards  of  the  gauze,  an  average  of  twelve  per  yard,  at  a  total 
cost  of  five  cents  a  dozen. 

Sponges  are  made  as  follows:  Let  the  two  yards  of  gauze  be 
cut  into  sixteen  squares.     One  of  the  raw  edges  of  a  center  square 


1:1    1    " 

BH 

Fig.  402. — Two  Yards  of  Gauze  Cut  into  Nine  Inch  Squares  to  Make  Twenty- 
four  Sponges;  Eight  Thick  and  Sixteen  Thin  Ones.  The  sponges  are  shown 
in  various  stages  of  preparation.  The  second  vertical  row  from  above  downward 
shows  the  five  steps  in  the  making  of  a  sponge  from  a  single  thickness  of  gauze. 
The  fourth  vertical  row  shows  the  four  steps  in  the  making  of  a  sponge  from  a 
double  thickness  of  gauze. 


is  folded  over  for  a  distance  of  two  inches,  the  two  sides  are  then 
folded  in,  the  first  for  a  distance  of  three  inches,  and  the  second 
for  a  distance  of  two  and  one-half  inches.  This  gives  a  strip  of 
gauze  seven  inches  long  and  three  inches  wide,  with  one  folded 
end  and  one  raw  end.  The  folded  end  is  folded  over  for  a  dis- 
tance of  two  and  a  half  inches.     This  end  is  opened,  and  the  rough 


GAUZE  685 

end  is  tucked  into  it  for  a  distance  of  two  inches.  This  gives  a 
sponge  measuring  two  and  one  half  by  three  inches,  composed  of 
twelve  thicknesses  of  gauze.  The  details  are  shown  in  the  accom- 
panying illustration  (Fig.  402). 

The  nine  inch  squares  which  lie  along  the  natural  folds  of 
the  gauze  have  already  one  folded  edge,  hence  one  begins  by  fold- 
ing in  the  two  sides.  This  gives  a  strip  nine  inches  long,  three 
inches  wide,  having  one  folded  end  and  one  rough  end.  The 
folded  end  is  now  folded  inward  a  distance  of  three  inches.  This 
end  is  opened  and  the  rough  end  is  tucked  in  for  a  distance  of 
three  inches.     This  gives  a  sponge  measuring  three  inches  square. 

If  one  wishes  to  have  sponges  more  nearly  uniform  in  size, 
this  can  be  accomplished  by  cutting  the  gauze  into  strips  within 
eight  inches  of  the  natural  folds.  When  the  four  strips  are  cut 
in  the  opposite  direction  there  will  be  eight  double  pieces,  meas- 
uring eight  by  nine  inches,  and  eight  single  pieces,  measuring- 
ten  by  nine  inches.  When  the  preliminary  two  inch  fold  has 
been  made,  a  single  piece  will  then  be  the  same  size  as  the  double 
pieces,  and  the  completed  sponge  will  have  the  same  area,  but 
not  quite  the  same  thickness  as  the  double  sponge. 

When  finished  these  sponges  should  be  wrapped  in  muslin  in 
packages  of  ten  (or,  as  some  prefer,  of  twelve),  marked,  and 
sterilized  by  steam. 

Gauze  in  Strips. — Pieces  of  gauze  one  yard  or  two  yards  in 
length  should  be  folded  lengthwise  three  times,  thus  making  a 
strip  four  and  a  half  inches  wide  and  eight  layers  thick.  This 
strip  should  be  rolled  up,  wrapped  in  muslin,  marked,  and  ster- 
ilized by  steam ;  or  if  preferred,  yard  or  half  yard  pieces  of  gauze 
may  be  folded  flat,  wrapped  up  in  similar  packages,  and  sterilized. 

These  pieces  of  sterilized  gauze  take  the  place  of  sterilized 
towels  and  sheets  to  provide  a  sterile  field  around  the  minor  oper- 
ative wounds.  In  this  way  the  bulk  of  the  material  necessary  for 
the  operation  is  considerably  reduced. 

Gauze  drains  are  sometimes  prepared  beforehand,  but  unless 
medicated  gauze  is  used,  this  is  unnecessary,  since  a  gauze  sponge 
can  in  a  moment  be  unfolded  and  converted  into  a  drain  by  fold- 
ing it  lengthwise  upon  itself. 

Gauze  Bandages. — Bleached  gauze  is  used  for  bandaging  to  a 
greater  extent  than  any  other  material  on  account  of  its  lightness, 


686  SURGICAL   DRESSINGS 

cheapness,  cleanly  appearance,  and  case  of  application.    It  is  made 

in  various  grades,  but  should  contain  not  less  than  40  X  44  threads 
to  the  inch.  Such  gauze  costs  by  the  piece  about  live  cents  a  yard. 
It  has  the  disadvantage  that  if  torn  into  strips  for  bandages,  the 
edges  arc  ragged,  and  the  finished  bandage,  no  matter  how  care- 
fully applied,  does  not  present  a  neat  appearance.  In  the  manu- 
factured gauze  bandages  which  are  cut  on  the  thread,  or  are  sliced 
from  a  tightly  wound  roll,  this  disadvantage  is  eliminated. 

A  gauze  bandage  is  more  porous  than  a  muslin  one,  and  is 
therefore  cooler.  It  is  not  nearly  so  firm  as  muslin,  so  that  more 
turns  are  ordinarily  employed.  The  initial  saving  of  expense 
per  yard  in  making  gauze  bandages  is  probably  lost  in  the  appli- 
cation. Gauze  has  one  distinct  advantage  over  muslin  in  its  ease 
of  application.  It  is  sufficiently  rough  to  cling  to  itself,  so  that 
the  turns  of  bandage  do  not  easily  slip  out  of  place.  Moreover, 
it  is  so  loosely  woven  that  it  tends  to  fit  the  part,  even  though  it 
is  not  applied  with  exactness. 

Unbleached  Muslin. — Muslin,  bleached,  or  more  often  un- 
bleached, is  used  for  slings,  for  handkerchief  or  first  aid  dress- 
ings, and  for  roller  bandages. 

The  muslin  employed  for  bandages  need  not  be  of  the  best 
quality,  since  even  the  cheaper  grades  are  sufficiently  firm  for 
the  purpose.  Such  a  muslin  costs  about  eight  cents  a  yard,  by 
the  piece.  A  muslin  bandage  has  certain  points  of  superiority 
over  gauze.  It  is  firmer  and  will  maintain  its  shape  for  a  long 
time  if  well  put  on.  It  is  not  so  easily  soiled,  and  can  be  washed 
and  ironed  and  used  again  many  times.  This  is  often  an  item  of 
importance  in  dressing  chronic  ulcers  of  the  leg,  etc.,  as  patients 
with  such  diseases  are  often  obliged  to  practise  rigid  economy. 
Muslin  tears  readily,  with  a  fairly  sharp  edge,  so  that  the  home- 
made bandages  present  a  good  appearance. 

Flannel. — The  flannel  selected  for  bandages  need  not  be 
finely  woven,  but  it  should  be  all  wool,  in  order  to  give  the  band- 
age its  maximum  of  elasticity,  which  is  the  special  merit  of  this 
type  of  bandage.  The  chief  objection  to  a  flannel  bandage  is  its 
expense.  It  can  be  repeatedly  washed  and  dried,  provided  luke- 
warm water  and  mild  soaps  are  used,  so  that  it  is  especially  use- 
ful as  a  bandage  of  the  legs,  for  chronic  ulcer  associated  with 
edema.     Whether  red  flannel  or  white  flannel  is  employed  is  a 


STOCKINETTE  687 

matter  of  taste.  The  former  has  no  superiority  to  the  latter,  and 
the  dye  sometimes  comes  out  and  stains  the  skin.  Flannel  band- 
ages are  easily  torn,  or  they  may  be  cut  on  the  bias,  the  elas- 
ticity being  thereby  considerably  increased.  The  latter  form  of 
bandage  tends  to  become  narrower  with  use — a  point  which 
should  be  taken  into  consideration  in  cutting  the  bandage.  A 
patient  should  be  directed  to  purchase  two  yards  of  flannel,  every 
thread  of  which  is  wool,  cut  it  on  the  bias  into  strips  four  inches 
wide,  lap  the  ends  of  these,  and  sew  them  together  flat,  in  order 
to  avoid  unnecessary  ridges.  This  will  give  him  three  bandages, 
so  that  he  can  wash  one  while  the  other  two  are  in  use.  A  simi- 
lar plan  may  be  followed  in  making  torn  flannel  bandages,  al- 
though if  one  wants  as  many  as  six  or  eight,  he  will  naturally 
use  a  piece  of  flannel  as  long  as  the  bandage  required.  Flannel 
suitable  to  this  purpose  costs  at  retail  about  forty  cents  per  yard, 
and  is  about  twenty-eight  inches  wide. 

Canton  Flannel.— Canton  flannel  is  used  chiefly  for  making 
many  tailed  bandages  and  other  bandages  of  the  abdomen  (!No.  33, 
p.  642).  It  is  too  thick  to  make  a  satisfactory  bandage  of  an 
extremity  or  the  head.  It  has  no  elasticity.  It  tears  well,  and 
costs  about  twelve  cents  a  yard  at  retail. 

Stockinette. — Stockinette  is  a  cotton  fabric  knitted  in  cylin- 
drical form.  It  is  sometimes  employed  for  bandages  on  account 
of  its  elasticity.  It  can  be  washed  and  used  repeatedly,  but  its 
thickness  makes  it  a  very  clumsy  material,  and  it  is  as  expensive 
as  flannel,  costing  twenty-five  cents  per  bandage  of  five  yards. 

Large  cylinders  of  stockinette  are  used  instead  of  an  under- 
shirt to  prevent  a  gypsum  or  plaster  of  Paris  jacket  from  coming 
into  contact  with  the  skin.  One  yard  or  more  of  the  material  is 
cut  off,  and  near  one  end  two  holes  are  cut  for  the  arms.  Thus 
all  seams  and  buttons  are  avoided. 

Bandages  having  considerable  elasticity  are  cut  from  cloth 
woven  like  crape  from  a  hard  thread  made  from  cotton  or  other 
vegetable  fibers.  These  bandages  are  well  suited  to  put  in  the 
hands  of  a  patient,  as  they  can  be  wound  spirally  around  a  limb, 
and  will  still  exert  a  fairly  even  though  light  pressure.  They  can 
therefore  be  applied  by  those  who  know  nothing  of  a  spiral  reverse 
or  a  figure  of  eight  turn  in  bandaging.  The  elasticity  of  fabrics 
of  this  sort  diminishes  rapidly  with  use. 


688  SURGICAL   DRESSINGS 

Silk.— Silk  in  the  form  of  black  ribbon  makes  an  excellent 
bandage  for  the  head  or  hand,  and  is  often  less  conspicuous  than 
a  white  bandage.  This  is  a  point  which  appeals  strongly  to  most 
patients.  The  expense  is  not  prohibitive  in  many  cases.  Suitable 
ribbon  two  inches  wide  can  be  obtained  at  twenty  cents  a  yard, 
and  for  such  a  bandage  four  or  five  yards  is  frequently  sufficient. 
Black  muslin  is  similarly  employed,  but  its  appearance  is  far 
inferior  to  that  of  silk. 

Rubber. — Rubber  is  used  in  two  ways  to  give  elasticity  to  a 
bandage.  A  long  strip  of  sheet  rubber  (pure  gum)  is  cut  of  the 
required  width  and  rolled  up  into  a  bandage.  If  the  rubber  of 
which  the  bandage  is  made  is  new  such  a  bandage  is  pretty  ex- 
pensive, but  a  two  inch  bandage,  five  yards  long,  costing  eighty 
cents,  will  retain  its  elasticity  for  many  months. 

Rubber  is  also  employed  in  the  form  of  longitudinal  threads 
to  give  elasticity  to  loosely  woven  cotton  fabrics.  These  rubber 
threads  break  with  use,  so  that  the  pressure  obtained  by  such  a 
bandage  soon  becomes  unequal.  It  is  very  serviceable  to  reduce 
swelling  in  acute  cases,  for  example,  in  synovitis  of  the  knee.  A 
two  inch  bandage,  five  yards  long,  costs  forty  cents. 

There  is  one  feature  of  a  sheet  rubber  bandage  which  for 
certain  purposes  is  a  distinct  drawback.  It  is  impervious  to 
moisture,  and  the  perspiration  is  therefore  retained  under  it.  It 
is  therefore  well  to  remove  it  every  night,  if  it  must  be  worn 
for  a  long  period  of  time,  so  that  both  bandage  and  skin  ean  be 
cleansed  by  soap  and  Avater. 

Crinoline. — Crinoline,  either  plain  or  cross-bar,  is  used  alone 
or  in  combination  with  gypsum  to  make  a  rigid  bandage.  The 
very  heaviest  type  of  crinoline  should  be  purchased  for  this  pur- 
pose. It  costs  about  nine  cents  a  yard,  and  is  a  yard  in  width. 
It  is  easily  torn  into  strips.  It  is  important  that  the  individual 
threads  of  the  crinoline  should  be  heavy,  as  this  will  give  it  more 
rigidity.  Such  a  bandage,  whether  or  not  it  contains  gypsum, 
should  be  loosely  rolled,  so  that  the  water  will  penetrate  through 
it  rapidly.  The  amount  of  starch  which  crinoline  contains  gives 
to  the  bandage  after  it  has  become  thoroughly  dry  a  considerable 
rigidity.  Unfortunately,  it  takes  from  twelve  to  twenty-four  hours 
for  it  to  dry.  During  this  time  the  part  must  be  kept  immobile,  or 
else  a  weak  joint  will  be  made  in  the  bandage.     It  is  very  light, 


OILED   MUSLIN,   SILK,   AND   PAPER  689 

and  is  therefore  adapted  for  use  upon  children,  and  as  a  band- 
age of  the  head  and  neck  after  extensive  dissection  of  cervical 
glands,  etc. 

Gutta-percha  Tissue. — This  material  is  gutta-percha  spread 
into  thin  sheets,  and  treated  in  such  a  manner  that  its  surface  is 
not  sticky.  It  is  sold  in  sheets  a  yard  square,  and  costs  from  fifty  to 
sixty  cents  a  yard,  according  to  the  weight,  whether  light,  medium, 
or  heavy.  [For  certain  purposes  this  is  the  best  impervious  material 
that  we  have.  It  is  absolutely  non-irritating  to  the  skin  or  to  a 
wound,  or  to  a  mucous  membrane.  It  never  adheres  to  a  wound, 
and  for  that  reason  makes  an  excellent  drain  when  folded  upon 
itself  to  make  a  narrow  strip,  or  when  it  is  used  to  cover  a  slender 
roll  of  gauze  (Fig.  306,  p.  571).  It  is  often  employed  in  burns 
and  skin-grafts,  to  keep  the  wounded  surface  moist,  and  to  protect 
it  from  contact  with  the  dressing.  Unfortunately,  it  cannot  be 
sterilized  by  heat,  as  it  shrivels  up  when  placed  in  water  even  a 
little  above  the  temperature  of  the  body.  It  is  commonly  steril- 
ized by  immersion  in  a  strong  bichlorid  solution  for  some  time 
before  its  employment.  Before  it  is  used  it  should  be  rinsed  with 
saline  solution  or  sterilized  water. 

Oiled  Muslin,  Silk,  and  Paper. — As  now  prepared,  oiled 
muslin  has  none  of  the  sticky,  disagreeable  features  formerly  at- 
tached to  both  oiled  muslin  and  silk.  It  is  flexible,  opalescent,  and 
costs  about  seventy-five  cents  a  square  yard.  Oiled  silk  prepared 
in  the  same  manner,  but  only  thirty  inches  wide,  costs  a  dollar 
a  yard.  These  materials  are  serviceable  to  prevent  evaporation 
from  a  poultice  or  wet  dressin'g,  and  to  prevent  saturation  of  the 
bedclothing  or  clothing  of  the  patient  during  the  continuance  of 
a  wet  dressing.  Cheaper  grades  of  oiled  muslin  can  sometimes 
be  obtained  in  dry-goods  stores.  Oiled  paper  makes  a  fairly  good 
substitute  for  oiled  muslin,  and  costs  only  three  cents  a  yard  by 
the  roll  of  twenty-five  yards.     It  is  twenty-four  inches  wide. 


LIGATURES  AND   SUTURES 

In  no  part  of  surgical  technique  is  sterility  of  so  great  impor- 
tance as  in  the  preparation  of  ligatures  and  sutures.  They  are 
implanted  in  wounded  tissues,  and  any  germs  which  they  may 
contain  are  placed  in  the  most  favorable  conditions  for  growth, 


690  SURGICAL  DRESSINGS 

being  harbored  in  a  foreign  body  (the  ligature),  and  supplied  with 
abundant  nutriment  in  the  form  of  extravasated  blood  and  dam- 
aged tissue  cells.  Any  material  for  ligatures  or  sutures,  therefore, 
which  cannot  be  sterilized  with  certainty  should  be  thrown  out 
of  the  surgical  armamentarium.  A  number  of  surgeons  have  at 
one  time  or  another  decided  that  catgut  fell  under  this  ban,  and 
have  refused  to  employ  it  under  any  circumstances.  It  is  now 
pretty  generally  admitted,  however,  that  it  can  be  sterilized  by  a 
number  of  methods  with  sufficient  certainty  to  warrant  its  general 
employment. 

Sutures  and  ligatures  are  primarily  divided  into  those  which 
are  capable  of  disintegration  within  the  tissues,  and  those  which 
remain  unchanged  either  permanently  or  for  a  very  long  period 
of  time.  The  names  absorbable  and  non-absorbable  are  applied 
to  these  two  classes.  All  the  non-absorbable  materials  can  be  ster- 
ilized by  boiling  in  water  or  in  a  steam  sterilizer. 

ABSORBABLE  SUTURES 

Catgut. — Various  animal  tendons,  strips  of  hide,  and  nerves 
have  been  employed  as  sutures  and  ligatures,  but  they  have  been 
almost  entirely  supplanted  by  catgut.  It  is  cheap,  it  can  always 
be  obtained  in  any  size,  and  in  strands  of  sufficient  length,  and  if 
properly  prepared,  it  has  great  strength.  Moreover,  it  is  quickly 
disintegrated  in  the  tissues,  the  ordinary  sizes  being  wholly  taken 
up  in  the  course  of  a  week  or  two,  so  that  no  foreign  body  remains 
in  the  wound  indefinitely.  Its  one  disadvantage  is  the  fact  that 
it  cannot  be  sterilized  by  steam  or  boiling  water,  for  in  both  of 
these  it  cooks  to  a  jelly  in  a  few  minutes. 

Sterilization  of  Catgut. — It  can  be  boiled  in  alcohol  in  a 
water  bath  or  sand  bath,  but  as  alcohol  boils  at  174°  F.,  the  tem- 
perature is  not  sufficient  to  kill  all  germs.  This  method  is  there- 
fore unreliable. 

Catgut  may  be  sterilized  by  dry  heat.  Boeckmann's  method  is 
as  follows:  The  catgut  is  soaked  in  ether  one  week  to  remove  the 
fat.  Single  strands  are  then  wound  in  rings,  and  each  wrapped 
in  paraffin  paper  and  sealed  in  a  paper  envelope.  The  envelopes 
are  placed  in  a  dry  sterilizer  and  heated  to  300°  F.  for  three 
hours  on  two  successive  days. 

Catgut  may  be  sterilized  by  chemicals.     Claudius's  method 


CATGUT  691 

is  the  simplest.  Commercial  catgut  without  any  preparation  is 
wound  in  single  layers  on  glass  spools  and  dropped  into  a  jar 
containing  one  part  of  iodin  and  one  part  of  potassium  iodid  to 
one  hundred  parts  of  distilled  water.  The  jar  is  tightly  covered 
and  allowed  to  stand  for  one  week.  For  use  the  spool  containing 
the  catgut  is  removed  and  immersed  in  sterile  water,  in  order 
to  free  the  catgut  from  the  excess  of  iodin.  Spools  which  have 
been  partially  used  can  be  resterilized  until  the  catgut  becomes 
brittle,  which  it  is  apt  to  do  if  it  remains  for  more  than  three 
months  in  the  above  mentioned  solution.  After  one  week's  im- 
mersion in  the  iodin  solution,  the  spools  may  be  removed  and 
kept  in  alcohol.  This  is  the  simplest  reliable  method  for  steril- 
izing catgut  in  the  office. 

Catgut  may  be  so  treated  with  chemicals  that  it  can  be  boiled 
in  water.  This  result  may  be  obtained  by  soaking  the  catgut  in 
a  solution  of  formaldehyde,  but  during  the  entire  process  the  cat- 
gut must  remain  tightly  stretched  upon  glass  plates  or  large  spools. 
A  simpler  method  is  that  of  Elsberg.  The  raw  gut  is  freed  from 
fat  by  immersion  in  ether  or  chloroform,  or  a  mixture  of  one  part 
chloroform  and  two  parts  ether.  It  is  then  wound  tightly  in  a 
single  layer  on  large  glass  spools,  having  a  hole  in  each  flange  in 
which  the  ends  of  the  gut  can  be  tied.  The  spools  are  boiled  for 
ten  minutes  in  a  saturated  solution  of  ammonium  sulphate  with 
one  per  cent  of  carbolic  acid.  The  spools  are  then  removed  with 
sterile  forceps,  rinsed  for  half  a  minute  in  warm  sterile  water, 
and  placed  in  strong  alcohol.  Partially  used  spools  can  be  re- 
sterilized,  and  the  solution  of  ammonium  sulphate  in  which  they 
are  boiled  can  be  used  indefinitely  by  the  addition  of  water  to 
take  the  place  of  that  which  has  evaporated. 

Catgut  may  be  sterilized  by  boiling  in  some  substance  which 
has  a  higher  boiling-point  than  water,  and  which  at  the  same  time 
will  not  so  alter  the  catgut  as  to  render  it  weak  or  brittle.  One 
of  the  best  substances  for  the  purpose  is  cumol,  which  boils  at 
about  330°  F.  The  method  is  a  little  too  complicated  for  office 
use. 

Catgut  may  be  sterilized  by  immersion  in  alcohol  heated  under 
pressure  in  order  to  obtain  a  high  degree  of  temperature.     This 
requires  special  apparatus,  and  is  not  a  method  suitable  for  gen- 
eral office  use. 
46 


692  SURGICAL   DRESSINGS 

Catgut  sold  in  sealed  glass  tubes  is  usually  prepared  by  one 
of  the  two  methods  last  mentioned.  Catgut  prepared  in  this 
manner  costs  from  ten  to  twenty-five  cents  a  ligature,  the  length 
of  which  varies  from  two  to  ten  feet,  according  to  the  size  of  the 
tube.  Envelopes,  each  containing  one  catgut  ligature,  about  two 
feet  long,  cost  from  five  to  ten  cents  a  piece. 

Commercial  catgut  comes  in  coils  of  one  hundred  feet,  cost- 
ing in  the  sizes  usually  employed  from  fifty  cents  to  one  dollar 
a  coil. 

Chromic  Catgut. — As  stated  above,  plain  catgut  disintegrates 
in  the  tissues  within  a  few  days.  Under  certain  circumstances 
this  is  a  disadvantage — for  example,  in  suturing  the  various  fas- 
cial planes  in  order  to  cure  a  hernia,  it  is  desirable  that  the 
sutures  shall  not  give  way  until  the  granulation  tissue  becomes 
firm.  For  such  purposes,  catgut  is  prepared  to  resist  disintegra- 
tion by  soaking  it  in  potassium  bichromate  or  chromic  acid  for 
twenty-four  or  forty -eight  hours.  A  good  method  for  office  use  is 
that  of  Elsberg,  mentioned  above,  with  the  addition  of  one  part  of 
chromic  acid  to  one  thousand  parts  of  the  ammonium  sulphate 
solution. 

The  longer  the  catgut  remains  in  the  solution  of  chromic 
acid  or  bichromate  of  potash,  the  harder  it  becomes,  and  the  longer 
will  it  resist  disintegration  in  the  body.  Chromic  catgut  or 
chromatized  catgut  is  sold  as  "  ten  day  catgut,"  "  twenty  day 
catgut,"  etc.  These  figures  are  not  very  reliable  estimates,  and 
should  not  be  too  implicitly  depended  upon.  If  the  catgut  re- 
mains too  long  in  the  hardening  solution,  it  will  become  practi- 
cally indestructible  in  the  tissues  of  the  body.  Buried  sutures  of 
such  material  have  often  been  removed  months  afterward  with- 
out their  showing  the  slightest  change. 

Kangaroo  and  Other  Animal  Tendons. — Kangaroo  ten- 
don was  formerly  employed  a  great  deal  for  the  deep  sutures  in 
hernia  operations.  The  tail  tendon  of  the  kangaroo  naturally 
splits  into  round  cords  which  make  excellent  sutures.  The  fibers 
in  the  leg  tendons  have  to  be  pulled  apart  mechanically,  like  the 
fibers  in  the  tendons  of  the  domestic  animals.  This  gives  a  rough 
thread  of  uncertain  strength.  Many  of  the  kangaroo  tendons  sold 
at  the  present  time  have  very  little  value.  Chromic  catgut  is 
gradually  taking  its  place. 


HORSEHAIR  693 

NON-ABSORBABLE   SUTURES 

Silk. — Twisted  or  braided  silk  is  by  far  the  commonest  mate- 
rial employed  for  sutures.  Some  surgeons  also  employ  it  for  liga- 
tures on  account  of  their  fear  of  infection  from  imperfectly  steril- 
ized catgut.  Black  silk  is  preferable  to  white  for  most  sutures,  as 
the  stitches  are  more  readily  seen  and  removed.  Silk  possesses  the 
very  great  advantage  of  being  easily  boiled  in  water  at  the  time 
of  the  operation.  Any  good  black  sewing  silk  answers  the  pur- 
pose satisfactorily,  although  many  surgeons  prefer  to  buy  specially 
prepared  and  sterilized  silk  sutures  in  sealed  glass  tubes,  costing 
from  fifteen  to  twenty-five  cents  each. 

For  tying  large  pedicles,  floss  silk  is  often  employed.  This 
is  a  loosely  twisted,  very  flexible,  and  strong  thread,  and  answers 
the  purpose  remarkably  well.  The  practise  of  mass  ligation, 
however,  is  falling  into  disuse,  as  it  is  now  generally  recog- 
nized that  the  blood-vessels  should  be  ligated  separately,  and 
the  wounds  in  the  other  tissues  should  be  closed  by  suture  with 
finer  thread. 

Silkworm  Gut. — This  material,  which  is  familiar  to  every 
fisherman,  is  obtained  from  the  silkworm  just  before  he  spins 
his  cocoon.  It  is  at  the  time  in  a  viscid  state,  and  is  pulled  out 
into  a  long  string  and  allowed  to  dry.  This  gives  a  hard,  elastic 
smooth  thread,  almost  like  wire.  These  threads  can  be  obtained 
in  bundles  of  one  hundred  of  dealers  in  fishing  tackle.  Such 
bundles  cost  from  forty  cents  upward,  according  to  the  size  and 
length  of  the  individual  threads.  They  can  be  sterilized  by  boil- 
ing in  water  or  by  steam ;  or  they  can  be  obtained  in  sealed  glass 
tubes,  costing  from  fifteen  to  twenty-five  cents  each.  Silkworm 
gut  is  even  less  irritating  in  the  tissues  than  silk,  and  is  an  excel- 
lent material  to  employ  when  deep  sutures  are  required. 

Horsehair.' — Black  or  brown  hairs  from  the  tail  of  a  horse 
make  excellent  sutures  for  skin  wounds.  They  should  be  washed 
with  soap  and  water,  and  then  with  alcohol.  When  needed  they 
are  easily  sterilized  in  boiling  water  or  in  steam.  They  are  not 
as  strong  as  silk,  but  they  are  able  to  resist  all  the  tension  which 
any  suture  ought  to  have.  They  can  also  be  obtained  ready  ster- 
ilized, six  in  a  tube,  at  twenty  cents ;  or  dry  in  bottles  or  en- 
velopes at  a  considerably  cheaper  rate. 


G04  SURGICAL  DRESSINGS 

Cotton  and  Linen  Thread. — Although  silk  is  generally 
used  in  preference  to  other  manufactured  threads,  this  is  largely 
a  matter  of  custom.  Cotton  or  linen  thread  is  easily  sterilized 
by  boiling,  docs  not  irritate  the  skin,  and  forms  a  perfectly  satis- 
factory suturing  material.  NTo  one  need  hesitate  to  use  either  in 
an  emergency,  nor,  foT  that  matter,  in  ids  regular  practise.  If  a 
colored  thread  is  used,  it  should  have  a  fast  dye,  or  else  it  should 
be  boiled  long  enough  to  extract  so  much  of  the  dye  as  is  easily 
soluble. 

Celluloid  Thread. — Thread  dipped  in  celluloid  is  often  em- 
ployed in  operations  upon  the  stomach  and  intestine  on  account 
of  its  impervious  character.  It  is  prepared  in  the  following  man- 
ner :  A  gray  linen  thread  is  boiled  in  one  per  cent  solution  of  car- 
bonate of  sodium,  wrapped  in  sterile  gauze,  dried  in  hot  air,  and 
then  dipped  in  a  solution  of  celluloid  which  is  heated  in  a  hot 
air  sterilizer.  It  is  dried  and  then  placed  in  a  3terile  receptacle 
until  wanted. 

Silver  Wire. — Pure  silver  w7ire  is  used  for  suturing  bones, 
and  also  by  some  operators  for  sutures  of  the  cervix,  perineum, 
harelip,  etc.  The  sizes  usually  employed  are  JSTos.  24  to  30.  Such 
wire  costs  about  two  dollars  and  fifty  cents  an  ounce.  It  is  also 
used  in  the  manufacture  of  filigrees,  employed  in  some  opera- 
tions for  hernia.  Other  kinds  of  wire,  and  notably  an  aluminum 
bronze,  are  employed  a  good  deal  in  Germany,  but  have  never 
obtained  much  popularity  in  this  country.  Antiseptic  powers  are 
claimed  for  them  by  their  advocates. 

DRAINS 

Glass  and  Metal  Drainage  Tnbes. — The  use  of  rigid 
tubes  for  drainage  is  not  now  so  general  as  it  was  at  one  time. 
Glass  tubes  are  easily  cleaned  both  inside  and  outside,  and  it  is 
easy  to  see  whether  they  are  clean  or  not;  but  owTing  to  their 
rigidity,  they  are  apt  to  cause  pain,  so  that  their  field  is  a  re- 
stricted one.  There  are  instances  in  which  it  is  important  to  use 
a  tube  which  will  not  collapse,  and  then  a  glass,  or  hard  rubber, 
or  metal  tube  is  employed ;  but  the  ordinary  purposes  of  drainage 
are  accomplished  just  as  well  by  the  use  of  a  flexible  rubber  tube, 
or  one  of  the  still  more  flexible  gauze  drains.     Glass  drainage 


GUTTA-PERCHA  DRAINS  695 

tubes  cost  from  ten  to  forty  cents  each,  according  to  their  shape 
and  size. 

Soft  Rubber  Drainage  Tubes. — Rubber  tubing  of  vari- 
ous calibers  forms  a  satisfactory  material  for  drainage.  Such 
tubing  costs  from  seven  to  twenty  cents  a  foot,  according  to  the  size 
and  quality.  The  drainage  tube  can  be  prepared  from  a  piece  of 
tubing  as  follows :  A  piece  of  tubing  of  the  required  size,  and  hav- 
ing a  smooth  surface,  is  selected  and  cut  to  the  required  length. 
The  end  which  enters  the  body  is  cut  obliquely,  and  its  sharp  edge 
trimmed  away  with  a  pair  of  scissors.  With  a  pair  of  curved 
scissors  two  or  more  oval  openings  are  cut  in  the  sides  of  the 
tube,  beginning  near  its  inner  end,  so  as  to  permit  the  escape 
of  pus  in  case  the  end  of  the  tube  is  obstructed  by  contact  with 
the  tissues.  The  long  axis  of  these  openings  is  made  parallel  to 
the  long  axis  of  the  tube,  so  that  the  tube  shall  not  be  unneces- 
sarily weakened  (Fig.  306,  p.  571).  A  little  practise  will  enable 
one  to  cut  these  openings  neatly ;  or  if  one  is  very  particular,  they 
may  be  burned  out  with  a  Paquelin  cautery.  This  gives  an  open- 
ing with  a  smooth  rounded  edge,  like  the  opening  of  a  velvet  eye 
catheter. 

Catheters  make  excellent  drainage  tubes.  Additional  holes 
should  be  cut  in  them  if  necessary.  The  rounded  tip  may  be 
left  or  removed,  according  to  circumstances.  If  it  is  allowed  to 
remain,  insertion  of  the  drainage  tube  is  thereby  facilitated. 

In  draining  large  wounds,  and  especially  if  irrigation  is  to  be 
employed,  two  tubes  should  be  used  and  fastened  together  at  the 
top  by  a  safety  pin  (Fig.  102,  J",  p.  176).  This  insures  freer 
drainage  and  allows  the  irrigating  fluid  to  flow  into  one  tube  and 
out  of  the  other. 

Gutta-percha  Drains. — Gutta-percha  tissue  is  an  excellent 
drainage  material,  especially  for  fresh  wounds  (see  p.  570).  It  is 
employed  in  two  ways:  A  piece  of  tissue,  an  inch  or  two  wide, 
is  folded  upon  itself  until  it  makes  a  strip  a  half  inch  wide,  more 
or  less.  Such  a  flat  strip  occupying  very  little  space  in  a  wound, 
and  not  adhering  to  the  tissues,  scarcely  disturbs  the  aseptic  heal- 
ing of  a  wound.  It  is  frequently  inserted  between  the  sutures  of 
a  wound  at  the  close  of  operation  in  order  to  facilitate  the  escape 
of  blood  and  serum.  Moreover,  if  the  operator  is  not  sure  of 
his  asepsis,  a  drain  of  this  character  will  allow  the  escape  of  any 


696  SURGICAL   DHESS1NGE 

pus  which  may  form,  and  prevent  its  burrowing  in  the  deeper 
tissues.  Two  days  after  operation  the  wound  should  be  re- 
dressed. If  its  appearance  is  satisfactory,  the  rubber  tissue  drain 
is  removed,  and  the  wound  is  allowed  to  unite  primarily.  If 
there  is  a  seropurulent  or  purulent  discharge  the  surgeon  may 
decide  to  allow  the  drain  to  remain  in  place  longer,  or  he  may 
think  it  better  to  remove  some  of  the  sutures  and  introduce  larger 
drains. 

Cigarette  Drains. — Gutta-percha  alone  gives  a  flat  drain;  com- 
bined with  gauze  it  forms  a  round  or  oval  drain.  This  is  known  as 
a  cigarette  drain.  A  roll  of  gauze  of  the  required  size  is  wrapped 
with  rubber  tissue,  as  the  tobacco  in  a  cigarette  is  wrapped  with 
paper.  Hence  the  name  "  cigarette  "  drain.  The  gauze  should 
project  slightly  from  the  lower  end  of  the  drain,  and  should  not 
be  too  tightly  rolled  (Fig.  30G,  p.  571).  If  the  gutta-percha  tis- 
sue shows  a  tendency  to  unwind,  its  edge  may  be  stuck  down  with 
chloroform.  Drains  of  this  character  are  often  employed  in  deeper 
wounds,  for  the  same  reasons  that  a  flat  gutta-percha  drain  is  em- 
ployed in  shallow  wounds ;  for  example,  after  appendectomy,  when 
there  is  a  possibility  that  suppuration  may  form  in  the  deeper 
tissues.  Such  a  drain  can  be  easily  removed,  since  the  only  por- 
tion which  can  become  adherent  is  the  gauze  at  its  lower  end. 
For  this  reason  the  gauze  should  not  project  far  beyond  the  gutta- 
percha tissue. 

When  gutta-percha  tissue  grows  old  it  becomes  brittle ;  hence 
it  should  be  tested  before  it  is  used  as  a  drain,  lest  a  portion  of 
the  drain  break  off  and  remain  in  the  wound.  The  tissue  can 
be  cut  with  scissors  or  torn.  It  has  a  distinct  grain,  so  that  in 
tearing  it  in  one  direction  the  motion  should  be  quick;  while  in 
tearing  it  in  the  other  direction,  one  must  tear  it  very  slowly  in 
order  to  follow  a  straight  line. 

A  finger  from  a  rubber  glove,  or  a  finger  cot  from  which  the 
tip  has  been  cut  away,  makes  an  excellent  casing  for  a  cigarette 
drain. 

Gauze  Drains. — Gauze  is  often  used  for  drainage,  either 
plain  or  impregnated  with  different  chemicals.  Its  chief  disad- 
vantage is  the  fact  that  it  adheres  so  closely  to  the  surface  of 
the  wound.  These  adhesions  give  way  in  five  days  to  a  week, 
but  by  that  time  granulations  may  already  have  grown  into  the 


HORSEHAIR   DRAINS  697 

meshes  of  the  gauze.  In  spite  of  this  drawback,  gau/,0  is  used 
for  drainage  far  more  than  any  other  material,  both  because  it  is 
always  at  hand,  and  because  it  is  so  flexible.  It  is  not,  however, 
a  good  thing  to  use  in  the  case  of  a  sensitive  patient  on  account 
of  the  pain  caused  by  its  removal.  The  most  favorable  time  for 
the  removal  of  a  gauze  drain  is  five  or  seven  days  after  its  inser- 
tion in  a  fresh  wound. 

The  gauze  drain  may  be  of  any  size.  A  flat  drain  is  formed 
by  folding  in  the  edges  of  a  strip  of  gauze  so  that  no  loose 
threads  appear.  The  two  ends  of  the  strip  are  then  brought  to- 
gether, and  the  fold  is  inserted  into  the  wound.  This  method 
facilitates  the  insertion  of  the  drain,  and  also  prevents  loose 
threads  from  remaining  in  the  wound  when  the  drain  is  with- 
drawn. 

A  roll  of  gauze  may  be  covered  with  gutta-percha  tissue, 
making  a  cigarette  drain  (see  opp.  page).  In  this  manner  adhe- 
sions between  the  gauze  and  the  surface  of  the  wound  are 
effectually  prevented,  and  the  drain  can  be  easily  removed  at  any 
time. 

A  Handkerchief  Drain. — If  the  wound  is  a  large  one,  and  it 
is  desired  to  keep  it  distended  with  a  large  quantity  of  gauze, 
adhesions  may  be  reduced  to  a  minimum  by  adopting  the  so-called 
Mikulicz  method.  This  is  also  called  a  handkerchief  drain.  A 
single  layer  of  gauze  like  a  handkerchief  is  spread  over  the  sur- 
face of  the  wound,  and  poked  into  all  the  recesses  into  which  it 
is  desired  to  carry  the  drains.  Large  flat  gauze  drains  made  in 
the  manner  above  described  are  then  carried  into  the  different 
portions  of  the  wound.  The  handkerchief  limits  adhesions  be- 
tween these  central  drains  and  the  wound,  so  that  they  can  be 
removed  without  much  difficulty  at  any  time.  When  they  have 
been  removed,  the  handkerchief  itself  being  only  a  single  layer, 
can  be  peeled  off  from  the  surface  of  the  wound  to  which  it  is 
adherent. 

Horsehair  Drains. — Small  drains  may  be  made  of  threads, 
or  horsehairs,  by  tying  a  number  of  them  together,  twisting  the 
bundle,  doubling  it  on  itself,  and  allowing  it  to  twist  backward 
(Fig.  306,  p.  571).  Drains  of  this  character  are  especially  serv- 
iceable in  scalp  wounds,  on  account  of  the  ease  with  which  they 
can  be  inserted  between  the  stitches. 


698  SURGICAL   DRESSINGS 

SPLINTS 

The  materials  in  common  use  for  rigid  splints  are  wood, 
sheet  metal,  and  wire  cloth.  Numerous  composite  materials  have 
been  made  for  splints,  but  they  have  never  come  into  general  use. 
The  essentials  of  a  good  splint  are  rigidity,  lightness,  and  cheap- 
ness. If,  in  addition  to  this,  the  splint  could  he  molded,  say 
by  warming  it  to  a  temperature  at  which  it  could  still  he  worked 
by  the  hands,  or  by  immersing  it  in  some  harmless  fluid,  it  would 
be  ideal.  Unfortunately,  we  possess  no  such  material.  Thus, 
hard  rubber  in  sheets  can  be  molded  at  a  high  temperature,  but 
cannot  then  be  handled.  A  composition  made  up  of  wood  pulp 
and  fiber  becomes  somewhat  more  flexible  when  soaked  in  water, 
and  can  be  easily  curved  in  one  direction,  as  can  pasteboard,  but 
it  cannot  be  curved  in  two  directions,  for  instance,  so  that  it  will 
fit  the  flexed  elbow.  Modeling  composition  is  easily  molded,  but 
it  lacks  strength. 

Wood  Splints. — Wood  remains  the  common  material  for  a 
ready-made  splint,  because  of  its  lightness  and  easy  accessibility. 
Bass  wood  an  eighth  of  an  inch  thick  answers  very  well.  This 
wood  is  easily  cut  with  a  knife,  and  is  not  inclined  to  split.  It 
has,  however,  no  great  strength.  In  most  cases  a  splint  of  wood 
must  be  padded  irregularly  to  make  it  conform  to  the  shape  of 
the  part  with  which  it  comes  in  contact. 

Coaptation  Splints. — If  a  wooden  splint  is  backed  with  a 
sheet  of  kid  or  adhesive  plaster,  and  is  cut  or  split  longitudinally 
into  a  number  of  pieces,  a  coaptation  splint  is  formed.  This  is 
of  use  to  fit  the  limb.  For  example,  after  fracture  of  the  cen- 
ter of  the  humerus  or  femur,  two,  three,  or  four  such  splints  are 
often  strapped  around  the  injured  portion  of  the  limb. 

Metal  Splints. — Tin,  aluminum,  and  other  metals  in  the 
form  of  thin  sheets  are  used  for  splints.  On  account  of  the  dif- 
ficulty of  cutting  them,  they  are  not  ordinarily  employed  except 
in  a  ready-made  form.  Such  manufactured  splints  are  extremely 
light  and  strong,  and  are  much  to  be  recommended  if  a  person 
has  to  wear  a  removable  splint  for  a  long  time.  The  splint  should 
be  perforated  to  permit  the  perspiration  to  evaporate,  and  made 
of  a  composition  which  does  not  easily  rust.  The  chief  objection 
to  these  splints  is  the  difficulty  in  having  on  hand  at  the  time  it 


METAL   SPLINTS 


699 


is  wanted  a  splint  that  will  exactly  fit  the  patient.  For  this  rea- 
son it  is  usually  better  in  acute  cases  to  mold  a  gypsum  splint  at 
the  time  it  is  required  (p.  707). 

There  is  one  form  of  tin  splint  which  the  writer  has  used 
with  such  success  that  he  can  highly  recommend  it,  even  though 
its  manufacture  dulls  the  edge  of  a  pair  of  scissors.  It  is  cut 
from  tin.  The  thin  tin  of  the  cracker  box  answers  perfectly. 
If  one  has  tin  shears  to  do  this  work  so  much  the  better ;  but  any 
heavy  scissors  will  answer  by  cutting  well  up  into  the  hinge.  A 
pattern  of  the  splint  should  first  be  cut  out  in  paper,  then  the 
splint  is  cut  from  the  tin.  Its  edge  is  turned  over  with  a  pair 
of  pliers,  or  by  gripping  it  with  the  handles  of  the  bandage  scis- 
sors, so  that  when  it  is  applied  to  the  hand  it  will  not  press  into 
the  skin.  The  proper  curve  is  then  given  to  the  portion  which  fits 
the  hand  and  the  portion  which  fits  the  finger,  and  the  two  are 
bent  at  the  required  angle  (Fig.  211,  p.  426). 

Wire  Netting. — A  coarse  wire  gauze,  eight  wires  to  the  inch, 
such  as  is  used  for  making  sieves,  can  be  used  to  make  a  posterior 


Fig.  403. — Angular   Splint   Made   in   the  Office   from  Wire   Cloth  with  no 
Other  Tool  than  a  Pair  of  Bandage  Scissors. 


right  angled  splint  for  the  elbow.  A  strip  is  cut  eight  or  ten 
inches  wide,  and  long  enough  to  reach  from  the  axilla  over  the 
point  of  the  elbow,  and  to  the  tips  of  the  fingers,  if  it  is  desired  to 
support  the  hand.  At  a  distance  of  eight  inches  from  one  end 
a  transverse  cut  is  made  on  either  side,  extending  one-third  of 


700  SURGICAL   DRESSINGS 

the  distance  across  the  splint.  Each  raw  edge  of  the  splint, 
for  a  distance  of  two  wires,  is  now  turned  over  and  pounded  down 
flat.  The  sides  of  the  splint  are  then  bent  up  so  as  to  give  the 
whole  splint  something  of  the  shape  of  a  half  cylinder.  It  is 
next  bent  at  the  required  angle,  at  the  level  of  the  two  cuts  that 
wire  made,  the  portion  intended  for  the  forearm  passing  within 
the  sides  of  the  portion  of  the  splint  intended  for  the  upper  arm. 
The  splint  is  fixed  in  this  position  with  wire  or  string,  tied 
through  at  least  two  places  on  either  side  (Fig.  403).  This 
makes  a  strong  and  light  angular  splint,  although  of  course  it 
does  not  fit  the  limb  with  any  degree  of  exactness. 

THE   USE   OF   GYPSUM— OR   PLASTER   OF    PARIS 

Gypsum  Bandages. — Gypsum,  often  called  plaster  of 
Paris,  has  virtually  superseded  such  materials  as  dextrin  and 
liquid  glass,  formerly  employed  for  rigid  bandages.  Gypsum 
can  be  used  in  two  Avays :  The  dry  gypsum  and  water  can  be 
stirred  up  until  a  cream  is  formed,  and  this  can  be  rubbed  into 
a  gauze  or  muslin  bandage  after  the  latter  has  been  partly  or 
wholly  applied  to  the  limb.  This  is  at  best  a  crude  method,  and 
does  not  make  the  best  use  of  the  two  materials,  owing  to  their 
very  imperfect  union.  The  other  and  better  method  consists  in 
incorporating  the  dry  gypsum  in  a  roller  bandage,  thoroughly  wet- 
ting the  latter  and  applying  the  bandage,  the  meshes  of  which  are 
then  full  of  moist  gypsum.  After  the  bandage  is  complete,  the 
plaster  sets,  having  taken  up  water  of  crystallization,  so  that  in 
ten  or  fifteen  minutes  the  bandage  will  be  quite  firm,  and  the 
patient  can  be  moved,  if  necessary.  It  takes  several  hours  for  all 
the  surplus  water  to  evaporate,  and  until  the  bandage  is  quite  dry 
it  should  not  be  subjected  to  any  rough  handling.  If  it  is  once 
cracked,  a  permanent  weak  spot  is  created,  which  can  be  only 
imperfectly  overcome  by  a  patch  of  additional  plaster. 

The  strength  of  a  gypsum  bandage  lies  in  the  combination  of 
the  fabric  which  has  power  to  resist  tearing  strains,  but  is  very 
flexible,  and  in  the  plaster,  which  has  no  elasticity,  and  is  very 
rigid,  but  which  breaks  easily  if  bent.  It  is  the  same  principle 
of  construction  now  so  widely  adopted  in  steel  and  concrete  build- 
ings.     It  is  of  the  greatest  importance  that  the  gypsum  used 


GYPSUM   BANDAGES  701 

should  be  freshly  calcined,  since  it  gradually  takes  up  moisture 
from  the  air,  and  becomes  slake.  Gypsum  which  is  partially  air- 
slaked  will  take  up  water  readily  like  so  much  sand,  but  no  chem- 
ical change  takes  place.  The  gypsum  never  sets,  in  other  words, 
and  when  it  drys  it  has  no  more  strength  than  dried  mud.  There 
is  nothing  in  surgery  more  irritating  than  the  attempt  to  immo- 
bilize a  limb  with  such  material.  It  is,  therefore,  the  part  of 
wisdom  to  test  the  gypsum  beforehand,  and  if  it  is  old  to  discard 
it.  The  best  gypsum  in  the  market  is  sold  under  the  name  of 
dental  plaster.  It  comes  in  cans,  holding  six  quarts  each,  and 
costs  seventy-five  cents  per  can.  If  a  can  is  kept  closed  from 
the  air,  and  in  a  dry  place,  it  will  maintain  its  freshness  even 
after  it  has  been  opened  for  a  number  of  weeks.  It  is  not  at  all 
necessary,  however,  to  employ  this  particular  preparation.  Every 
store  where  painters'  materials  are  sold  and  every  decorator  and 
worker  in  plaster  keeps  a  more  or  less  fresh  supply  of  gypsum. 
If  the  material  is  really  fresh,  it  has  a  tremendous  strength  after 
it  has  set.  I  have  put  on  bandages  made  from  gypsum  obtained 
at  a  paint-store  that  one  could  hardly  crack  with  a  hammer ;  and 
have  attempted  to  put  on  others  put  up  by  the  best  surgical  house 
in  America,  and  bought  of  a  respectable  druggist,  that  were  just 
a  mess  of  wet  cloth  and  white  sand  when  they  were  finished.  It 
is  all  in  the  age  of  the  gypsum.  As  it  is  usually  easier  to  obtain 
fresh  gypsum  than  it  is  to  obtain  freshly  made  gypsum  bandages, 
every  one  should  know  how  to  prepare  his  own.  The  method  here 
given  requires  no  especial  apparatus,  not  even  a  bandage  roller. 

Preparation  of  Gypsum  Bandages. — The  articles  required  are 
two  pounds  of  fresh  gypsum,  costing  five  cents,  six  or  eight 
yards  of  crinoline,  costing  about  sixty  cents,  a  board,  or  the 
top  of  an  old  table,  and  a  table  knife  with  a  straight  back.  The 
crinoline  is  torn  into  strips  from  two  to  four  inches  in  width,  ac- 
cording to  the  part  of  the  body  to  be  bandaged,  and  rolled.  The 
end  of  a  bandage  is  spread  out  upon  the  board  for  a  distance  of 
two  feet.  Three  or  four  knifefuls  of  dry  gypsum  are  dumped 
down  upon  it.  The  meshes  of  the  crinoline  are  scraped  full  of 
the  gypsum  by  drawing  the  back  of  the  knife  two  or  three  times 
along  it,  and  this  portion  of  the  bandage  is  loosely  rolled  up  (Fig. 
404).  ~No  central  core  is  made,  as  when  a  muslin  bandage  is 
rolled  by  hand,  as  it  is  better  that  the  center  of  the  bandage  should 


702  SURGICAL  DRESSINGS 

be  hollow.  Another  two  feet  of  bandage  are  spread  out  flat, 
scraped  full  of  gypsum,  and  rolled  up.  This  process  is  continued 
until  the  whole  strip  of  bandage  has  been  converted  into  a  roll. 
The  bandage  is  prevented  from  unrolling  by  a   pin  or  an  elastic 


Fig.    404. — -Making   Gypsum   Bandages  from   Crinoline,  Showing   the   Various 
Stages  of  their  Preparation. 

band  around  it;  or  it  may  simply  be  wrapped  up  in  paper.  The 
tendency  of  a  beginner  is  to  put  too  much  gypsum  into  the 
bandage. 

To  make  such  a  bandage  does  not  require  more  than  five  min- 
utes. It  has  two  points  of  superiority  over  a  commercial  bandage. 
Crinoline  is  employed  instead  of  gauze,  so  that  the  appearance 
of  the  completed  plaster  bandage  is  better  and  its  strength  is 
somewhat  greater.  Secondly,  the  bandage  is  loosely  rolled,  so 
that  the  water  will  permeate  it  quickly.  It  is  impossible  for  a 
commercial  bandage  to  be  made  in  this  manner.  Shipping  it 
about  the  country  would  rattle  the  gypsum  almost  entirely  out 
of  the  meshes  of  the  crinoline.  Hence,  the  commercial  bandage  is 
made  of  gauze,  is  overfilled  with  gypsum,  and  is  rolled  tightly. 
Such  a  bandage  does  not  wet  quickly,  and  indeed  should  be  loosely 
rerollcd  by  hand  before  being  dropped  into  water,  if  one  wishes 
to  get  the  best  result  from  its  use. 

From  four  to  six  gypsum  bandages  are  required  to  immobilize 
the  ankle  of  an  adult,  for  instance,  after  a  fracture  of  the  ankle. 
Four  will  give  a  light  bandage  extending  from  the  toes  to  the 
knee,  and  six  a  heavy  bandage  covering  the  same  area.     There 


A  CIRCULAR   GYPSUM   SPLINT  703 

is  an  almost  universal  tendency  to  make  a  plaster  bandage  twice 
or  three  times  as  thick  as  it  should  be.  The  unnecessary  weight 
loads  down  a  patient,  and  renders  the  removal  of  the  hand  age 
unnecessarily  difficult.  Other  fabrics  than  crinoline  can  be  em- 
ployed in  the  manufacture  of  gypsum  bandages,  provided  their 
meshes  are  not  too  fine.  Gauze  answers  very  well.  Recently  a 
company  has  been  introducing  bandages  in  which  a  fine  wire 
cloth  is  employed. 

A  Circular  Gypsum  Splint — or  Plaster  Cast. — The  tech- 
nique of  application  of  gypsum  bandages  is  important,  if  one 
wishes  to  get  the  best  out  of  this  material.  The  limb  of  the  patient 
should  be  shaved,  washed,  and  dried.  It  should  then  be  covered 
with  a  thin  layer  of  cotton  or  other  elastic  material.  This  may  be 
held  in  place  by  a  few  spiral  turns  of  a  gauze  bandage-.-  The  sheet 
wadding  which  is  employed  by  dressmakers  is  an  excellent  mate- 
rial with  which  to  cover  the  limb.  It  tears  readily  into  strips,  has 
a  uniform  thickness  which  it  is  difficult  to  give  to  absorbent  cotton, 
and  if  wound  spirally  around  the  limb  it  will  remain  in  place 
without  a  gauze  bandage.  Or  the  limb  may  be  covered  with  a 
flannel  bandage. 

A  deep  bowl  or  jar  containing  sufficient  warm  water  to  more 
than  cover  the  bandage  when  standing  on  end  should  be  at  hand. 
One  loosely  rolled  gypsum  bandage  is  placed  on  end  in  the  water. 
Bubbles  of  air  at  once  rise  to  the  surface,  and  continue  to  do  so 
until  the  bandage  is  wet  through.  It  should  then  be  lifted  from 
the  jar,  squeezed  partially  dry  with  both  hands,  and  applied.  One 
should  avoid  milking  the  gypsum  out  of  the  bandage  while  it  is 
in  the  water. 

The  application  of  a  gypsum  bandage  is  similar  to  that  of  a 
dry  roller  bandage,  but  there  are  certain  points  of  difference. 
The  gypsum  bandage  never  slips,  so  that  it  is  unnecessary  to 
draw  it  taut.  Tension  during  the  application  is,  in  fact,  a  dis- 
advantage, since  the  unequal  pressure  tends  to  make  ridges  in 
the  inner  surface  of  the  completed  splint.  The  strength  of  the 
splint  is  in  the  material,  and  the  aim  should  therefore  be  to 
apply  it  evenly.  Reverses  should  never  be  made,  since  the  end 
which  they  serve  in  a  dry  bandage  is  better  accomplished  in 
plaster  by  the  use  of  "  darts."  A  figure  of  eight  of  the  type  often 
employed  in  dry  bandages  when  the  upper  circles  of  several  figures 


704 


SI  RGICAL    DRESSINGS 


of  eight  exactly  overlie  each  ether  is  seldom  desirable.  This  is 
apt  to  make  the  splint  thicker  in  places  than  in  others,  and  it 
offers  no  advantages  which  cannot  be  obtained  by  the  use  of  the 
short  figure  of  eight  with  a  dart. 

The  moistened  bandage  is  anchored  by  a  single  circular  turn, 
and  is  at  once  carried  spirally  upward.  The  overlapping  should 
not  be  for  more  than  one-half  the  width  of  the  bandage.  No 
traction  should  be  applied  in  an  attempl  to  make  the  two  edges  of 


Fig.  405. — Making  a  "Dart"  in  a  Gypsum  Bandage. 

the  bandage  lie  smooth.  As  soon  as  any  fulness  of  the  lower  edge 
is  noticed,  the  bandage  should  be  carried  sharply  upward  and 
around  the  limb,  and  sharply  downward  again.  The  fulness  in  the 
lower  edge  of  the  ascending  portion  of  this  short  figure  of  eight  is 
taken  up  by  the  change  in  the  direction  of  the  bandage.  The  ful- 
ness in  the  descending  portion  is  kept  up  out  of  the  way  by  the 
thumb  and  finger  of  one  hand,  and  is  pasted  smoothly  backward 
against  the  rest  of  the  bandage  (Fig.  405).  The  dart  thus  made 
and  folded  back  sticks  instantly.  Another  spiral  turn  may  now 
be  introduced,  and  then  a  figure  of  eight,  or  the  figures  of  eight 


A  CIRCULAR   GYPSUM  SPLINT  705 

each  with  a  dart  in  the  downward  turn  may  he  applied  without 
intervening  spirals.  In  this  manner  any  portion  of  any  limb,  no 
matter  what  its  shape,  can  be  evenly  covered  with  the  bandage, 
various  turns  of  which  should  be  well  rubbed  together  before  the 
gypsum  has  time  to  set. 

In  starting  a  second  bandage,  one  should  select  the  descend- 
ing turn  of  a  figure  of  eight  some  three  or  four  inches  below  the 
upper  margin  of  the  first  bandage.  The  second  bandage  should 
be  directed  downward,  so  that  it  will  exactly  follow  the  first  band- 
age around  the  limb  and  upward.  This  avoids  any  break  between 
the  first  bandage  and  the  second.  A  sufficient  number  of  figures 
of  eight,  or  spiral  turns,  are  then  applied  to  complete  the  cover- 
ing of  the  required  area.  If  a  thicker  bandage  is  required,  the 
third  one  should  be  begun  at  the  bottom  and  should  cover  the  area 
covered  by  the  first  one.  The  fourth  one  should  overlap  the  third 
in  the  manner  already  described,  and  should  cover  the  area  cov- 
ered by  the  second  one.  This  method  of  application  gives  a  more 
even  and  stronger  splint  than  if  each  bandage  were  made  to  cover 
but  a  small  area,  and  that  to  a  considerable  thickness. 

If  the  gypsum  bandages  have  been  applied  in  the  manner 
described,  and  care  has  been  taken  to  make  all  lines  exactly  paral- 
lel that  should  be  so,  and  to  see  that  the  pattern  made  by  the 
intersection  of  the  ascending  and  descending  portions  of  the  figure 
of  eight  turns  lies  exactly  in  the  median  line  of  the  limb,  the 
finished  plaster  splint  will  be  much  admired ;  but  if  the  turns 
of  the  bandages  have  been  irregularly  applied,  it  may  be  better 
to  obscure  them  by  the  application  of  additional  gypsum,  cream. 
Some  of  the  powdered  gypsum  should  be  stirred  into  water  until 
thin  paste  is  made.  This  should  be  rubbed  evenly  over  the  sur- 
face of  the  finished  splint,  and  smoothed  off  by  means  of  a  wet 
cloth  or  compress.  It  is  also  a  good  plan  to  give  the  splint  this 
smooth  surface  whenever  it  is  likely  to  be  soiled  by  escaping 
urine,  discharge  from  a  wound,  etc. 

It  is  of  the  utmost  importance  that  during  the  application  of 
gypsum  bandages  the  limb  should  be  held  exactly  in  the  position 
which  it  is  desired  to  maintain.  Flexion  of  a  joint  or  correction 
of  a  misplaced  fracture  is  possible  while  the  plaster  is  still  soft, 
but  it  breaks  the  commencing  crystallization,  and  makes  a  weak 
spot  in  the  splint.     Furthermore,  the  position  of  the  limb  should 


706  SURGICAL   DRESSINGS 

be  carefully  maintained  until  the  plaster  has  fully  set.  This  re- 
quires perhaps  ten  or  twenty  minutes,  according  to  the  freshness 
of  the  gypsum.  During  this  period  the  limb  should  be  held,  or 
so  arranged  upon  loosely  filled  sandbags,  or  hard  pillows,  that  its 
weight  is  distributed  over  a  considerable  surface,  and  does  not  rest 
upon  a  single  transverse  ridge. 

It  takes  from  twelve  to  twenty-four  hours  for  a  plaster  splint 
to  become  thoroughly  dry,  and  during  this  period  the  air  should 
have  access  to  the  surface.  Adjacent  portions  of  the  body,  whether 
above  or  below  the  splint,  may,  of  course,  be  covered. 

As  soon  as  the  plaster  splint  has  been  applied,  the  circula- 
tion in  the  portion  of  the  limb  beyond  it  should  be  examined. 
Color  should  promptly  return  after  pressure  made  with  the  finger 
is  removed,  and  the  toes  or  finger-tips  should  not  be  much  colder 
than  those  of  the  corresponding  extremity.  If  the  quality  of  the 
circulation  is  doubtful,  one  should  wait  a  few  minutes  to  see  if 
it  improves.  If  it  does  not,  the  plaster  splint  should  be  split  from 
end  to  end,  and  any  underlying  constricting  bandage  should  be 
cut.  This  will  relieve  the  undue  pressure.  It  is  not  necessary 
to  remove  the  splint.  An  outside  bandage  of  gauze  or  other 
flexible  material  should  be  applied  over  it  to  keep  it  in  position. 

Removal  of  a  Gypsum  Splint. — Various  saws  and  scissors  have 
been  devised  for  cutting  through  a  gypsum  splint.  Most  of  them 
are  extremely  unsatisfactory.  They  work  well  enough  on  certain 
portions  of  the  splint,  but  when  it  lies  close  to  a  bone  beneath, 
or  follows  a  convex  surface,  like  the  front  of  the  ankle,  these 
instruments  give  a  great  deal  of  trouble.  On  the  whole,  the  most 
satisfactory  tool  is.  a  sharp-bladed  knife.  This  may  be  as  large 
as  a  pruning-knife,  or  as  small  as  an  ordinary  penknife;  either 
one  answers  perfectly  well  if  the  blade  is  sharp. 

The  surgeon  selects  the  line  upon  which  the  plaster  splint  is 
to  be  cut,  and  marks  the  same  with  a  swab  of  wet  absorbent  cottons 
He  then  draws  the  knife  the  full  length  of  it,  making  only  moder- 
ate pressure.  He  draws  it  through  the  line  a  second  time,  mak- 
ing a  little  firmer  pressure.  He  then  draws  the  cotton  once  more 
along  the  line,  filling  the  cut  with  water.  As  the  knife  is  drawn 
through  the  cut  the  third  time,  the  blade  is  inclined  sharply  to 
one  side.  At  the  fourth  cut  it  is  sharply  inclined  to  the  opposite 
side.     In  this  manner  a  gutter  is  cut  out  of  the  plaster,  which  will 


MOLDED   GYPSUM  OR  PLASTER   SPLINTS  707 

prevent  the  knife  from  u  binding  "  in  a  deep  cut.  These  vari- 
ous steps  are  repeated  until  the  cut  has  extended  through  the 
plaster  to  the  sheet  wadding  or  absorbent  cotton  beneath.  This 
material  prevents  the  knife  from  cutting  the  patient  unless  an 
unreasonable  amount  of  force  is  applied.  By  following  this 
technique  one  can  easily  cut  through  a  gypsum  splint  of  the  leg 
and  foot  in  five  or  six  minutes. 

To  Cut  a  Window  or  Fenestra. — This  is  necessary  in  order 
to  permit  the  dressing  of  a  wound  without  the  removal  of  a  gyp- 
sum splint,  as  in  cases  of  compound  fracture,  etc.  If  there  is 
more  than  one  wound,  it  is  usually  better  to  apply  molded  plaster 
splints,  both  longitudinal  and  circular,  rather  than  to  cut  numer- 
ous fenestras. 

In  every  case  the  site  of  the  wound  should  be  determined  by 
longitudinal  and  transverse  measurements  made  before  the  limb 
is  bandaged.  The  appearance  of  the  limb  is  so  altered  by  the 
application  of  a  plaster  splint  that  it  is  unwise  to  trust  to  mem- 
ory as  a  guide  to  the  cutting  of  the  fenestra.  The  gauze  dressing 
which  is  used  to  cover  the  wound  should  correspond  to  the  size  of 
the  fenestra  to  be  cut,  and  it  should  be  held  in  place  by  only  one 
or  two  circular  turns  of  bandage.  This  will  make  it  unnecessary 
to  cut  through  many  thicknesses  of  gauze,  and  the  plaster  splint 
will  fit  the  limb  more  accurately  than  it  will  if  many  thicknesses 
of  gauze  are  wound  around  the  limb. 

The  fenestra  is  marked  out  with  a  knife  or  pencil,  according 
to  the  measurements  taken  before  the  limb  was  covered.  The 
gypsum  splint  is  then  cut  through  layer  by  layer  in  the  man- 
ner described  for  the  removal  of  a  splint.  This  should  be  done 
after  the  plaster  has  set,  but  before  it  has  fully  dried.  The  inner 
dressing  may  be  removed  immediately  and  reapplied,  or  it  need 
not  be  disturbed  until  later.  In  every  case  a  thick  pad  or  com- 
press should  be  used  to  fill  up  the  gap  made  by  the  removal  of 
the  plaster.  This  should  be  held  in  place  with  a  firm  circular 
bandage;  otherwise  the  portion  of  skin  underlying  the  fenestra 
will  likely  become  very  edematous. 

Molded   Gypsum,    or   Plaster   Splints.— Splints  freshly 
made  from  gypsum  bandages  and  molded  to  the  injured  part  before 
the  gypsum  has  set,  are  of  the  greatest  use  in  the  treatment  of  frac- 
tures of  the  upper  and  lower  extremity.     They  can  be  applied 
47 


708  SURGICAL  DRESSINGS 

immediately  after  a  fracture,  since  they  do  not  dangerously  in- 
terfere with  the  swelling  of  the  limb  as  a  circular  plaster  splint 
may  do.  They  are  sufficiently  light  and  can  be  applied  and  re- 
moved at  pleasure;  while  unlike  wood,  they  can  be  molded  to  fit 
the  curved  portions  of  the  body.  Such  splints,  weight  for  weight, 
have  not. the  strength  of  a  circular  plaster  splint,  nor  are  they 
to  be  recommended  when  there  is  a  marked  tendency  toward 
recurrence  of  displacement  in  the  case  of  a  fresh  fracture. 

In  most  cases  two  molded  splints  are  desirable.  Each  should 
be  broad  enough  to  encircle  one-third  or  one-fourth  of  the  limb 
to  which  it  is  to  be  applied.  The  curve  thus  given  to  the  splint 
adds  greatly  to  its  strength.  Its  length  should  be  determined  by 
measurement  before  the  splint  is  made.  For  light  splints  a  single 
roller  bandage  suffices,  while  for  heavier  ones  two,  or  even  three, 
may  be  required.  In  some  instances  additional  circular  splints 
are  employed  to  fix  the  lateral  ones  in  place  and  make  them  more 
rigid. 

The  required  length  of  the  splint  is  marked  on  a  board  or 
marble  slab.  The  gypsum  bandage  is  sunk  in  water,  and  after  it 
ceases  to  bubble  it  is  lifted  out  and  squeezed  partially  dry  (see 
p.  703).  Its  loose  end  is  then  held  to  the  board  by  the  thumb 
and  finger  of  the  left  hand,  and  enough  of  the  bandage  is  un- 
rolled to  pass  the  second  mark  upon  the  board.  The  unrolling 
should  be  done  in  the  air,  so  that  when  the  bandage  is  allowed 
to  sink  upon  the  board,  it  may  be  free  from  longitudinal  wrinkles. 
The  left  hand,  now  free,  takes  the  bandage  from  the  right,  and 
carries  it  toward  the  left  until  the  fold  of  the  bandage  just  lies 
on  the  right  hand  mark.  The  thumb  and  finger  of  the  right 
hand  prevent  it  from  being  drawn  beyond  this  mark,  and  the  left 
hand  unrolls  sufficient  bandage  to  pass  the  left  hand  mark.  This 
second  layer  of  bandage  is  allowed  to  rest  upon  the  first,  and  the 
two  are  rubbed  together  by  a  stroke  of  the  right  hand  made  from 
left  to  right  before  the  bandage  is  changed  from  the  left  hand 
to  the  right.  The  bandage  is  carried  backward  and  forward  in 
this  manner  until  the  splint  has  the  required  thickness.  A  little 
time  is  saved  if  an  assistant  guards  the  turns  of  the  bandage  at 
one  of  the  marks,  and  rubs  the  various  layers  together. 

The  completed  splint  should  be  at  once  molded  to  the  bare 
limb.     Hairs  should  have  been  shaved  off,  or  pasted  to  the  skin 


MOLDED   GYPSUM,   OR   PLASTER  SPLINTS  709 

with  vaseline,  so  that  they  will  not  become  imbedded  in  the  plas- 
ter; or  the  splint,  before  its  application,  may  be  J  mod  with  a 
single  strip  of  canton  flannel,  which  should  slightly  project  at 
the  edges  and  ends.  The  splint  is  applied,  molded  by  the  fingers 
to  fit  the  part,  and  held  in  place  by  a  gauze  bandage  until  it  sets. 
It  may  then  be  left  in  place,  or  the  surgeon  may  prefer  to  remove 
it,  and  to  lay  it  aside  a  day  until  it  becomes  thoroughly  dry  before 
reapplying  it.  The  latter  is  a  good  plan  to  follow  in  the  late 
treatment  of  fractures.  The  splint  or  splints  may  then  be  cov- 
ered with  some  cotton  or  woolen  fabric  stitched  so  as  to  make  a 
complete  casing.  This  should  be  just  loose  enough  to  follow  easily 
the  curves  of  the  splint. 

If  two  or  more  splints  are  to  be  used,  the  second  should  be 
made  as  rapidly  as  possible,  so  that  it  may  be  applied  before  the 
first  has  time  to  set. 

A  molded  plaster  splint  may  also  be  made  as  above  described, 
except  that  a  fine  wire  cloth  is  substituted  for  the  crinoline  in  the 
preparation  of  the  bandage.  The  splint  so  made  is  considerably 
stronger  than  one  in  which  crinoline  is  employed. 

Reenforcing  a  Gypsum  Splint. — It  is  often  desirable  to  increase 
the  strength  of  a  molded  or  circular  gypsum  splint  in  order  to 
prevent  it  breaking  at  some  point  where  the  strain  is  greatest; 
for  example,  opposite  the  groin  in  the  case  of  a  spica  of  the  groin. 

The  material  used  for  reenforcing  the  gypsum  splint  is  gen- 
erally a  light  strip  of  metal,  measuring  half  an  inch  or  more  in 
width  and  one-thirty-second  of  an  inch  or  more  in  thickness,  ac- 
cording to  circumstances.  A  coarse  wire  cloth  cut  into  strips,  or 
even  thin  strips  of  wood,  may  also  be  used  for  the  purpose.  The 
technique  of  application  is  as  follows,  in  the  case  of  a  circular 
bandage:  The  limb  is  encased  with  protective  material  (see  p. 
703),  and  it  is  then  bandaged  with  gypsum  bandages  until  one- 
half  of  the  required  number  of  bandages  has  been  employed.  The 
thin  metal  strips  are  then  bent  until  they  accurately  fit  the  part 
in  a  longitudinal  direction.  They  are  covered  in  by  the  remain- 
ing gypsum  bandages,  and  the  dressing  is  complete. 

In  certain  cases  it  is  desirable  to  give  the  metal  strip  a  greater 
hold  upon  the  plaster;  for  example,  if  a  circular  splint  is  made 
in  two  portions,  with  a  gap  between  them  to  permit  of  the  dress- 
ing of  wounds,  or  of  extension  of  the  limb  in  cases  of  compound 


710  SURGICAL   DRESSINGS 

fracture.  Under  such  circumstances  a  piece  of  tin  should  be  riv- 
eted to  either  end  of  the  metal  strip,  and  slightly  curved  to  con- 
form to  the  shape  of  the  limb. 

If  the  reenforcing  strips  of  coarse  wire  cloth  are  used  in  a 
molded  plaster  splint,  they  should  be  shaped  to  the  limb  before 
the  splint' is  made.  Such  reenforcing  material  can  then  be  incor- 
porated in  the  molded  splint  as  the  latter  is  made. 

Gypsum  or  Plaster  Casts. — It  is  often  desirable  to  obtain 
a  cast  of  some  portion  of  the  body  for  purposes  of  demonstration, 
or  for  means  of  comparison  in  order  to  show  the  change  produced 
by  a  growth,  or  during  treatment,  or  as  a  guide  to  the  manu- 
facture of  orthopedic  apparatus.  Such  a  cast  may  be  obtained  in 
several  ways ;  thus  every  circular  plaster  bandage,  when  removed, 
is  a  mold  of  the  part  with  which  it  has  been  in  contact.  It  is 
usually,  however,  a  very  imperfect  mold,  since  even  with  the 
greatest  care  it  is  impossible  to  make  the  bandage  press  equally 
upon  every  portion  of  the  skin.  A  better  method,  therefore,  is  to 
employ  a  semifluid  cream,  or  paste,  made  of  powdered  gypsum 
and  water.  The  portion  of  the  body  of  which  a  cast  is  desired  is 
half  submerged  in  this  paste,  and  kept  there  until  the  latter  sets. 
Its  upper  surface  is  then  greased,  and  a  sufficient  amount  of  paste 
is  added  to  completely  surround  the  portion  of  the  body  in  ques- 
tion. When  this  has  also  set,  the  two  half  molds  are  removed. 
When  they  are  applied  together,  they  form  a  complete  mold,  from 
which  a  more  or  less  perfect  cast  can  be  obtained,  according  to 
the  skill  of  the  workman. 

It  is  often  necessary  to  obtain  a  cast  of  the  foot  from  which 
to  make  braces  for  the  correction  of  fiatfoot.  To  do  this  success- 
fully requires  not  a  little  skill,  and  the  description  of  the  technique 
employed  will  enable  one  to  make  a  cast  of  any  other  portion  of 
the  body  in  a  similar  manner.     The  directions  are  as  follows: 

Remove  by  shaving  or  clip  short  the  hairs  on  the  dorsum  of 
the  toes  and  foot.  Oil  or  grease  every  bit  of  the  skin,  so  that 
it  may  not  adhere  to  the  plaster.  Let  the  patient  lie  down 
with  the  outer  side  of  the  affected  foot  downward.  Make  an  oval 
ring  with  a  heavy  bath  towel,  and  cover  it  with  four  or  five  thick- 
nesses of  newspaper.  Place  the  foot  in  the  depression  thus  caused, 
and  fill  the  depression  with  the  gypsum  cream  or  plaster  until 
it  rises  to  the  level  of  the  second  toe,  and  is  half  way  up  the 


GYPSUM  OR   PLASTER  CASTS  711 

heel  (Fig.  406).  This  gypsum  cream  is  made  by  stirring  freshly 
calcined  powdered  gypsum  into  warm  water.  The  water  should 
not  be  too  warm,  as  the  slaking  of  the  gypsum  increases  the  heat 
somewhat.  It  is  a  matter  of  nice  judgment  to  determine  when 
the  cream  is  just  thick  enough.     As  a  general  rule  it  is  better  to 


Fig.  406. — Making  a  Cast  of  the  Foot  with  Gypsum.     The  Mold  Half 

Completed. 

have  it  too  thin  than  too  thick,  since  if  it  will  not  pour  readily, 
it  may  not  flow  into  all  crevices,  and  air  spaces  will  remain  be- 
tween the  skin  and  the  plaster,  and  an  imperfect  mold  will  result. 
If  the  cream  is  too  thin,  it  does  not  set  readily,  and  flows  away 
from  the  foot.  When  of  just  the  right  consistency  it  can  be  heaped 
up  around  the  foot,  and  will  remain  there  while  adapting  itself 
to  the  shape  of  the  latter. 

When  the  first  half  of  the  mold  has  set,,  its  upper  surface 
should  be  oiled  or  greased,  so  that  the  second  half  may  not  stick 
to  it.  A  fresh  lot  of  gypsum  cream  is  prepared  and  is  poured 
very  slowly  over  the  exposed  portion  of  the  foot.  Care  should 
be  taken  to  see  that  it  is  everywhere  of  sufficient  thickness  to 
permit  of  its  removal  without  breaking. 

When  the  second  half  of  the  mold  has  set,  it  is  trimmed  down 
somewhat,  so  that  its  area  of  contact  with  the  first  half  shall  be 
reduced  to  a  zone  about  half  an  inch  wide.  It  is  then  carefully 
wedged  up  from  the  first  half  and  removed.     The  foot  is  then 


12  SURGICAL   DRESSINGS 


withdrawn  from  the  first  half  of  the  mold,  and  both  parts  are  set 
aside  to  dry  (  Fig.  407). 

When  the  mold  is  dry,  or  even  before  it  is  dry,  if  one  is  very 
careful,  its  whole  interior  is  oiled  or  greased  and  its  two  halves 


Fig.  407. — Making  a  Cast   of   the  Foot  with  Gypsum.      The  two  halves  of  the 
mold  have  been  removed  from  the  foot,  trimmed,  and  set  up  to  dry. 

are  tied  together  in  their  correct  relation.  Its  interior  is  then 
filled  with  a  gypsum  cream  somewhat  thinner  than  that  employed 
in  making  the  mold.  The  mold  should  be  held  in  such  a  position 
during  this  process  that  air  may  find  ready  exit.  Mold  and  cast 
should  be  set  aside  to  allow  the  latter  to  become  thoroughly  hard. 
The  molds  are  then  broken  and  removed,  and  slight  irregularities 
in  the  cast  are  trimmed  off,  or  filled  in  with  plaster  cream,  as  the 
case  may  require.  In  the  case  of  flatfoot  it  is  usually  customary 
to  partially  correct  the  deformity  in  the  cast  by  shaving  away 
some  of  the  plaster  from  the  under  or  inner  side  of  the  cast  before 
sending  it  to  the  brace-maker.  The  area  which  the  brace  should 
cover  should  be  marked  on  the  cast  with  pencil. 

Plaster  Jacket. — A  plaster  jacket  is  merely  a  heavy  circular 
gypsum  splint  of  the  trunk,  or  possibly  of  the  trunk  and  head.  It 
is  usually  applied  for  some  condition,  such  as  tuberculosis  of  the 


PLASTER  JACKET  713 

spine,  which  renders  it  necessary  to  continue  the  treatment  for 
many  months;  hence,  the  jacket  should  be  made  with  great  care. 

In  most  cases  it  is  desirable  that  the  patient's  spine  should  be 
fully  extended  during  the  application  of  the  jacket,  and  until  the 
gypsum  has  set.  This  is  accomplished  by  suspending  the  patient 
from  a  tripod,  or  from  a  hook  in  the  ceiling,  a  part  of  the  weight 
being  borne  upon  straps  which  pass  under  the  arm,  but  as  much 
as  possible  of  the  weight  resting  on  straps  passed  under  the  chin 
and  occiput.  The  patient  should  wear  a  light  balbriggan  under- 
shirt or,  still  better,  a  cylinder  of  stockinette,  with  two  holes  for 
the  arms.  In  either  case  a  strip  of  gauze  bandage  should  be  placed 
between  the  stockinette  and  the  back,  and  another  one  between  the 
stockinette  and  the  chest,  to  be  used  as  scratching  strings.  These 
will  add  greatly  to  the  patient's  comfort,  and  will  serve  to  remove 
a  considerable  amount  of  cast  off  epithelium. 

Bony  prominences,  such  as  the  spinous  processes  of  the  verte- 
bras, should  be  protected  from  undue  pressure  by  strips  of  saddler's 
felt  placed  on  either  side  of  them.  Bandages  employed  for  the 
jacket  should  be  three  inches  in  width.  From  six  to  twelve  are 
needed,  according  to  the  size  of  the  patient.  The  manner  of  their 
application  is  in  general  that  of  an  ascending  or  descending  spiral 
bandage  of  the  chest  and  abdomen,  with  additional  forward  and 
backward  turns  over  the  shoulders,  or  combined  with  the  figure  of 
eight  bandage  of  both  axillae  (p.  618).  It  is  of  the  greatest  im- 
portance that  the  various  layers  of  bandage  should  be  thoroughly 
rubbed  together  as  they  are  applied. 

After  the  gypsum  has  set,  but  before  it  is  fully  dry,  the  upper 
and  lower  margins  of  the  plaster  jacket  and  the  holes  for  the  arms 
are  trimmed  out  smoothly  with  a  sharp  knife.  The  stockinette  is 
then  turned  over  these  raw  edges,  and  held  in  place  by  stitches 
passing  between  the  upper  and  lower  margins. 


CHAPTER    XXIII 
GENERAL  ANESTHESIA1 

GENERAL  REMARKS 

Underlying  Principles. — For  practical  purposes  general  or 
complete  anesthesia  is  an  induced  sleep,  brought  about  in  large 
measure  by  the  introduction  into  the  system  of  mildly  poisonous 
drugs,  which  benumb  the  sensations  and  cloud  or  obliterate  con- 
sciousness. Some  of  the  drugs  employed  are  pronounced  sleep 
producers,  while  others  have  a  greater  effect  in  dulling  the  sensa- 
tions. There  has  been  a  long  search  for  something  which  will 
obliterate  the  sensation  of  pain  throughout  the  body  while  leaving 
the  patient  in  full  possession  of  his  consciousness.  A  hypnotized 
person  may  be  incapable  of  perceiving  pain  while  retaining  con- 
sciousness in  other  respects ;  but  the  possibilities  of  such  complete 
hypnosis  are  limited.  The  nearest  practical  approach  to  conscious- 
ness without  pain  is  seen  in  spinal  anesthesia.  While  the  advan- 
tages of  retained  consciousness  during  some  operations  are  self- 
evident,  it  is  no  less  obvious  that  the  obliteration  of  consciousness 
is  often  desirable. 

With  the  introduction  of  new  forms  of  apparatus  and  of  new 
ways  of  administering  anesthetics,  both  singly  and  in  combina- 
tion, the  subject  of  anesthesia  has  become  complex  and  not  a  little 
confusing  to  the  beginner.  There  are,  however,  certain  under- 
lying jn-inciples  which  must  be  observed  no  matter  what  the  tech- 
nic,  if  success  is  to  be  achieved.  Much  has  been  written  on  the 
responsibility  of  the  anesthetist.  It  is  true  that  the  patient's  life 
is  placed  in  his  hands.     A  similar  situation  exists  at  a  wedding — 

1  The  advantages  of  general  anesthesia  in  the  performance  of  many  operations 
which  are  themselves  of  a  minor  character,  make  it  desirable  to  include  in  this 
book  a  chapter  on  anesthesia.  The  subject  is  treated  in  a  general  way,  in  the 
hope  that  it  may  prove  serviceable  to  all  beginners  in  anesthesia,  the  need  of  in- 
struction in  this  field  having  been  widely  recognized  in  the  past  few  years. 
714 


ANESTHESIA   IN   CHILDREN  715 

not  at  a  funeral.  Let  the  ceremony  of  an  operation  suggest  the 
joy  of  the  former  rather  than  the  gloom  of  the  latter.  Flippancy 
on  the  part  of  the  anesthetist  is  inexcusable,  but  a  manifest  delight 
in  the  performance  of  his  task  will  both  cheer  the  patient  and 
inspire  confidence,  for  a  person  usually  does  well  what  he  takes 
pleasure  and  pride  in  doing. 

There  is  also  much  difference  in  opinion  as  to  who  should  give 
an  anesthetic;  some  advocating  that  a  nurse  should  be  fitted  for 
this  work,  others  holding  that  every  graduate  doctor  should  be 
sufficiently  trained  to  give  satisfaction  as  an  anesthetist.  Still 
others  hold  that  anesthesia  should  be  made  a  specialty  and  its  prac- 
tice restricted  by  law  to  doctors  with  special  qualifications  f ?i  '":. 
There  is  one  rule,  however,  upon  which  nearly  everyone  will  agree, 
and  that  is,  that  the  person  who  gives  the  anesthetic  should  not  be 
the  one  who  performs  the  operation,  however  brief  it  may  be.  This 
rule,  even  though  not  a  legal  requirement,  should  be  disregarded 
only  in  emergencies. 

Confidence. — The  first  step  toward  a  successful  anesthesia 
is  to  gain  the  confidence  of  the  patient.  Previous  acquaint- 
ance may  have  established  it,  but  usually  the  anesthetist  is  almost 
or  quite  a  stranger.  Under  such  circumstances  minute  details  are 
of  great  moment.  Personal  neatness,  familiarity  with  the  appa- 
ratus, an  unhesitating  method  of  procedure,  all  produce  an  instan- 
taneous effect  on  the  unusually  alert  mind  of  the  patient.  Just 
how  the  anesthetist  is  to  impress  his  personality  on  the  patient  in 
the  few  minutes  that  are  at  his  disposal — whether  by  earnest  con- 
versation, by  almost  complete  silence,  by  irrelevant  remarks 
("  jollying  "),  by  a  hand  clasp,  or  by  some  other  way — each  indi- 
vidual must  decide  for  himself.  In  some  manner  this  confidence 
must  be  gained  if  possible. 

Fear  should  be  dispelled  by  the  person  and  conversation  of  the 
anesthetist.  The  suggestion  of  an  easy  sleep  or  interesting  dream 
will  often  favor  the  beginning  of  the  anesthesia  to  an  extent 
surprising  to  one  who  sees  it  tried  for  the  first  time.  Such  a 
speedy  and  quiet  induction  also  lessens  post-anesthetic  nausea  and 
vomiting. 

Anesthesia  in  Children. — With  young  children  the  ideal 
plan  is  to  produce  the  anesthesia  during  a  natural  sleep.  This  can 
usually  be  accomplished  with  chloroform  if  the  mask  is  held  sev- 


716  GENERAL   ANESTHESIA 

oral  inches  away  from  the  face  and  only  a  few  drops  arc  placed 
on  it,  and  it  is  not  brought  nearer  until  the  little  patient,  has 
become  accustomed  to  the  odor  of  chloroform  as  shown  by  undis- 
tni'bed  respiration.  It  may  then  be  cautiously  advanced  and  the 
amount  of  chloroform  increased,  but  wmenever  the  breathing  is 
disturbed,  or  the  child  moves  the  distance  of  the  mask  should  be 
increased.  In  this  way  one  can  usually  chloroform  a  sleeping 
child  in  five  minutes.  If  the  child  is  awake  it  is  sometimes  besl 
to  act  promptly;  otherwise  it  may  grow  more  and  more  fright- 
ened until  it  becomes  hysterical. 

There  are  several  instances  on  record  of  deaths  of  children 
and  adults  at  the  beginning  of  anesthesia  which  were  due  un- 
questionably to  fright.  In  some  of  them  no  anesthetic  had  been 
given. 

Bystanders. — The  presence  of  a  third  person  at  the  beginning 
of  anesthesia  is  always  desirable.  The  touch  of  a  friend's  hand 
gives  the  patient  comfort.  But  the  third  person,  whether  friend, 
nurse,  or  surgeon,  should  be  quiet  and  never  attempt  to  manage 
the  proceedings — a  function  which  belongs  absolutely  to  the  anes- 
thetist. 

Physical  Examination. — The  physical  condition  of  the  pa- 
tient should  be  ascertained,  and  if  there  is  any  weakness  of  heart, 
lungs,  arteries,  kidneys,  etc.,  the  anesthetist  should  know  it.  How- 
ever, organic  lesions,  unless  extreme  in  degree,  rarely  interfere 
w7ith  the  smooth  progress  of  a  properly  given  anesthetic.  Their 
effect  is  seen  in  convalescence,  especially  if  the  operation  is  a  pro- 
longed one.  Hence  the  knowledge  of  the  existence  of  such  lesions 
should  lead  the  anesthetist  to  make  the  anesthesia  as  light  as  pos- 
sible, while  it  is  even  more  important  for  the  surgeon  to  make  the 
operation  short  and  to  minimize  the  operative  trauma. 

Preparation. — ]STo  patient  should  be  anesthetized  with  a  stom- 
ach fidl  of  food.  Vomiting,  choking,  and  death  may  be  the  result. 
It  has  happened  more  than  once.  In  case  of  emergency  operations 
a  full  stomach  should  be  washed  out  before  the  anesthetic  is  given. 
This  should  also  be  the  rule  in  cases  of  intestinal  obstruction  and 
peritonitis  with  vomiting.  On  the  other  hand,  it  is  unnecessary  to 
starve  a  patient  for  a  whole  day  previous  to  anesthesia,  and  it  is  a 
good  plan  to  give  six  or  eight  ounces  of  water,  or  even  coffee  or 
tea,  within  three  or  four  hours  of  the  anesthetic.     Milk  should 


POSITION  717 

never  be  allowed.  It  often  coagulates  in  masses  larger  than  any 
masses  of  solid  food  which  might  be  swallowed. 

The  clothing  should  be  loose  around  the  neck,  chest,  and  abdo- 
men. This  rule  applies  to  surgical  dressings  and  to  the  usual 
forms  of  clothing.  The  body  should  be  well  protected  against 
undue  loss  of  heat. 

Loose  objects,  including  small  plates  of  teeth,  should  be  re- 
moved from  the  mouth.  Full  plates  cannot  be  swallowed,  and  they 
often  aid  breathing  by  keeping  the  lips  and  cheeks  apart.  If  so, 
they  should  not  be  removed. 

]STose,  lips,  and  chin  should  be  lightly  smeared  with  cold  cream 
or  oil.  Eyes  should  be  covered  with  a  compress  of  gauze  or  a 
towel. 

One  should  always  have  at  hand  plenty  of  gauze  cut  and  folded 
in  the  proper  size  and  shape  for  use  as  swabs,  and  in  the  apparatus 
for  anesthesia ;  two  or  three  clean  towels ;  a  wedge  for  opening  the 
jaws ;  a  tongue  forceps ;  a  hypodermic  syringe,  and  stimulants. 

Position. — An  anesthetic  should  be  given  in  a  horizontal  or 
semi-recumbent  position.  There  is  no  objection  to  a  pillow.  In 
exceptional  cases  of  cardiac  or  pulmonary  disease  the  patient  may 
breathe  better  when  sitting  bolt  upright.  In  such  a  case  the  anes- 
thetic should  be  started  in  the  position  in  which  the  patient  is 
most  comfortable.  As  unconsciousness  develops  the  position  may 
be  gradually  changed. 

The  neck  should  not  be  unduly  flexed,  twisted,  nor  overex- 
tended, especially  in  stout  persons ;  a  slight  change  in  the  position 
of  the  head  may  seriously  embarrass  breathing,  or  equally  relieve 
it  if  made  in  another  direction. 

The  arms  of  the  patient  should  rest  at  his  sides  with  the  fore- 
arms either  flexed  or  extended.  In  the  latter  position  the  thumbs 
may  be  slipped  under  the  buttocks  to  prevent  the  arms  from  falling 
off  of  the  table.  It  is  dangerous  to  allow  the  arm  to  hang  over  the 
edge  of  the  table.  Pressure  upon  the  musculo-spiral  nerve  in  the 
middle  of  the  humerus  may  cause  a  paralysis  of  the  extensor  mus- 
cles of  the  thumb  and  hand  lasting  some  weeks.  It  is  equally 
dangerous  to  draw  the  arm  up  over  the  head.  As  the  muscles  of 
the  shoulder  relax  the  head  of  the  humerus  sags  down  against  the 
nerves  coming  from  the  brachial  plexus,  and  an  extensive  paralysis 
in  the  arm  and  hand  may  result. 


718  GENERAL  ANESTHESIA 

Restraint. — Xu  unnecessary  weight  should  be  placed  on  the 
chest  or  abdomen.  The  patient's  system  is  sufficiently  taxed  with- 
out raising  with  each  inspiration  the  arm  of  an  assistant  carelessly 
resting  on  the  patient's  chest.  It  is  the  duty  of  the  anesthetist  to 
call  attention  to  this.  If  it  is  necessary  to  restrain  the  patient, 
pressure  should  not  be  made  over  the  chest  or  abdomen.  The  fore- 
arms, the  thighs  just  above  the  knees,  and  the  forehead  arc  the 
points  where  pressure  is  most  serviceable.  If  a  tinner  control  is 
needed  the  shoulders  and  hips  may  be  held  down.  There  arc  emer- 
gencies when  the  rule  not  to  compress  chest  or  abdomen  must  be 
temporarily  broken.  I  once  knew  an  anesthetist  left  alone  with 
an  alcoholic  to  sit  astride  the  patient's  abdomen,  hooking  his  own 
feet  under  the  table,  while  with  one  hand  he  grasped  the  patient's 
neck  and  the  cone,  and  with  the  other  poured  on  the  ether.  The 
patient's  arms  and  legs  were  flying  furiously,  but  he  did  not  escape. 
But  there  is  more  credit  in  avoiding  such  an  emergency  than  in 
meeting  it. 

Should  the  patient  be  restrained  as  a  matter  of  routine  either  by 
tying  or  by  holding?  Opinions  differ  on  this  point.  It  is  an  econ- 
omy of  labor  to  have  a  patient  tied  hand  and  foot  to  the  operating 
table,  especially  if  the  anesthetist  is  an  uncertain  quantity ;  but  it 
is  not  a  high  ideal  to  aim  at.  With  plenty  of  assistants  manual 
restraint  is  better,  but  a  patient  should  not  be  held  until  there  is 
need  for  it.  Theoretically  any  rational  adult  patient  can  be  so 
gently  anesthetized  that  there  will  be  no  struggling.  Practically 
this  is  not  always  the  case,  so  that  restraint  is  sometimes  unavoid- 
able. It  should  never  be  rough,  and  only  felt  by  the  patient  when 
he  makes  an  effort  to  move.  The  feeling  of  being  held  may  stir  up 
the  fight  in  an  otherwise  quiet  patient.  But  the  chief  cause  of 
struggling  during  anesthesia  is  a  feeling  of  suffocation.  The  anes- 
thetic is  crowded  too  fast  or  not  enough  air  is  allowed,  so  that  the 
patient  naturally  fights  for  breath.  Under  these  circumstances  it 
is  the  anesthetist  that  needs  to  be  held  rather  than  the  patient.  A 
poor  anesthesia  gives  a  struggling  patient. 

Place. — When  circumstances  permit,  it  is  well  to  anesthetize 
the  patient  on  the  operating  table.  Delay  in  transportation  and 
lifting  of  the  patient  are  thereby  avoided.  There  is  also  a  distinct 
advantage  in  letting  the  patient  while  conscious  arrange  himself 
comfortably  on  the  table  where  he  is  to  lie  for  an  hour  or  so.    Pads 


INDUCTION  719 

can  be  adjusted  so  that  the  back  will  not  be  strained.  This  simple 
precaution  may  save  the  patient  from  lying  awake  all  night  with 
an  aching  back.  In  many  cases  timidity  of  the  patient  or  the 
necessity  of  using  a  single  operating  room  for  several  patients  in 
succession  makes  it  impracticable  to  anesthetize  in  the  operating 
room.  If  the  operating  table  is  equipped  with  four-  or  six-inch 
wheels  it  pan  be  easily  pushed  from  room  to  room,  so  that  the 
patient  may  be  anesthetized  upon  it. 

Preliminary  Medication. — There  are  certain  distinct  bene- 
fits obtained'  by  the  preliminary  administration  of  a  narcotic  to  a 
patient  wl^i  is  about  to  take  an  anesthetic.  Fear,  excitement, 
nervousness  are  lessened  or  dispelled.  Unconsciousness  is  more 
easily  produced.  The  patient  is  less  sensitive  to  pain,  and  hence 
a  lighter  degree  of  anesthesia  will  be  satisfactory.  Less  anes- 
thetic is  employed.  Excessive  secretion  of  saliva  and  mucus  is 
checked.  Against  the  use  of  such  drugs  it  may  be  urged  that  the 
pupillary  reflex  is  somewhat  interfered  with ;  that  they  delay  re- 
turn to  consciousness,  and  hence  protection  from  inhalation  of 
fluids  by  normal  swallowing  is  postponed ;  they  D  increase  the 
patient's  p&gt-operative  thirst ;  they  do  not  directly  decrease, 
and  probably  in  some  cases  increase,  post-operative  nausea  and 
vomiting. 

The  wise  plan  seems  to  be,  therefore,  to  reserve  their  employ- 
ment for  nervous  and  excitable  persons  and  for  muscular  and  alco- 
holic persons,  varying  the  dose  according  to  the  weight  of  the  indi- 
vidual. Morphin  (gr.  -J  to  4)  with  atropin  (gr.  y^-  to  yfo)  given 
hypodermically  one  half  hour  before  the  anesthetic  is  probably  the 
best  combination,  though  some  prefer  scopolamin  or  hyoscin  (grs. 
rio"  t°  Tiro)  instead  of  atropin.  One  should  not  fall  into  the 
routine  use  of  these  or  any  other  drugs.  In  a  majority  of  in- 
stances a  satisfactory  anesthesia  can  be  produced  without  their 
aid.  They  are  poisons  which  have  to  be  eliminated.  They  should 
be  used  only  in  special  cases  in  which  their  benefits  outweigh  their 
disadvantages. 

Induction. — Every  inhalation  anesthesia  should  begin  grad- 
ually, increase  slowly,  and  continue  without  interruption  until  the 
patient  is  fully  anesthetized.  After  that  only  so  much  of  the  anes- 
thetic should  be  given  as  is  necessary  to  keep  the  patient  just  at 
the  proper  level.     But  the  amount  used,  whether  small  or  large, 


720  GENERAL  ANESTHESIA 

should  be  given  continuously,  or  as  nearly  so  as  possible,  in  order 
to  keep  the  patient  steadily  at  the  required  level.  Alternate  heavy 
closes  of  the  anesthetic,  with  intervals  in  which  the  anesthetic  has 
to  be  removed  altogether  to  permit  the  patient  to  come  back  to  a 
safer  condition,  is  the  anesthesia  of  a  tyro.  It  is  like  the  begin- 
ner's attempt  to  steer  a  bicycle.  He  swings  first  to  the  right  and 
then  to  the  left  of  the  line  he  is  trying  to  follow.  It  is  well  to  let  the 
patient  try  the  apparatus  before  it  contains  any  anesthetic.  There 
should  be  no  valves  nor  tubes  so  small  as  to  hamper  in  the  least 
degree  an  easy,  full  breathing. 

The  first  breaths  of  the  anesthetic  should  be  well  diluted  with 
air  or  oxygen.  The  immediate  dangers  of  chloroform  and  ethyl 
chlorid  are  greatly  increased  by  giving  a  concentrated  vapor.  ( !on- 
centrated  ether  vapor  is  most  irritating,  and  even  nitrous  oxid 
should  be  thus  diluted  at  first. 

Respiration. — Respiration  should  be  free,  but  not  forced  or 
hurried.  Primary  anesthesia  may  be  hastened  by  forced  deep 
breathing;  but  unless  one  plans  to  stop  the  anesthetic  as  soon  as 
primary  anesthesia  is  obtained,  such  forced  respiration  is  a  dis- 
advantage. It  is  followed  by  a  suspension  of  rgsjpiration  in 
which  the  patient  often  regains  a  bewildered  half-conscious- 
ness and  refuses  to  permit  the  anesthetic  to  continue,  so  that 
force  has  to  be  used  or  else  the  patient  allowed  to  regain  full 
consciousness.  Then,  too,  there  is  danger  in  forced  respiration 
that  the  patient  will  obtain  too  concentrated  a  vapor  of  the  an- 
esthetic. 

As  anesthesia  progresses  and  self-control  vanishes  it  is  the  an- 
esthetist's duty  to  see  that  no  harm  comes  to  the  patient.  His 
chief  duty  is  to  watch  the  respiration  and  see  that  it  is  not  ham- 
pered by  a  bad  position  of  the  head,  by  tightly  compressed  lips, 
by  a  sagging  backward  of  the  jaw  and  tongue,  by  the  accumulation 
of  mucus  or  fluid  in  the  throat,  or  by  the  arms  of  assistants  or 
weights  placed  upon  the  neck  or  chest.  The  best  position  for  the 
head  is  in  the  median  line  or  turned  slightly  to  one  side.  Some 
persons  breathe  better  when  the  head  is  on  a  level  with  the  shoul- 
ders and  some  when  it  is  slightly  raised.  If  the  shoulders  are 
raised  on  a  sand  bag  in  order  to  expose  the  neck  for  operation,  a 
smaller  bag  or  pad  should  be  at  hand  to  place  under  the  head  to 
avoid  too  great  extension  of  the  neck. 


SIGNS  OF  SURGICAL  ANESTHESIA  721 

Pulse. — Every  anesthetist  should  practice  mil  i  1  he  is  able  to 
test  the  pulse  in  the  carotid' and  temporal  arteries  as  easily  as  in 
the  radial.  He  can  then  form  his  own  judgment  of  the  heart's 
action,  and  not  have  to. ask  a  nurse  or  other  bystander  what  the 
pulse  is  like.  It  is  a  mistake,  however,  to  judge  of  the  state  of 
anesthesia  solely  by  the  pulse.  It  varies  too  much  and  too  rapidly. 
Moreover,  it  almost  always  outlasts  respiration,  and  may  be  fairly 
good  when  respiration  has  stopped  altogether  and  the  patient  re- 
quires immediate  attention.  It  is  valuable  as  showing  by  its  rapid- 
ity and  weakness  that  excessive  hemorrhage  has  taken  place  or  that 
the  operative  trauma  has  been  prolonged  or  severe.  Under  such 
circumstances  the  anesthetist  may  be  able  to  give  the  operator 
warning  in  time  to  save  the  patient  from  more  than  he  can  bear. 
Intra-abdominal  manipulation  produces  a  shock  which  shows  itself 
at  once  in  rapid,  feeble  pulse  and  altered  respiration.  If  the 
manipulation  is  stopped  the  symptoms  are  quickly  relieved.  In 
deep  dissections  of  the  neck  or  axilla,  pressure  or  traction  of  the 
pneumogastric  nerves  and  sympathetic  ganglia  may  also  give  a 
weak  and  rapid  pulse. 

Signs  of  Surgical  Anesthesia. — The  time  required  to  pro- 
duce surgical  anesthesia  varies  between  less  than  two  minutes  in 
some  cases  in  which  gas  or  ethyl  chlorid  is  used,  to  twenty  minutes 
in  difficult  cases  in  which  ether  is  used  from  the  start.  With  such 
wide  variations  an  average  is  meaningless. 

As  anesthesia  is  produced  respiration  becomes  deep  and  regu- 
lar. Nervous  tension  of  the  muscles,  if  such,  existed,  disappears. 
The  patient  is  unable  to  answer  questions  and^gives  no  sign  that 
they  are  heard.  Keflexes  to  touch  and  pain  are-next  lost.  A  good 
way  to  test  these  is  by  an  attempt  to  raise  the,  upper  lid.  The 
effort  will  be  resisted  by  a  patient  not  completely  anesthetized. 
Some  anesthetists  make  the  stupid  mistake  of  touching  the  eyeball 
or  the  margin  of  the  eyelid  with  the  finger  to  determine  the  pres- 
ence of  the  conjunctival  reflex.  When  there  are  other  reflexes  eas- 
ily and  safely  obtainable  there  is  no  excuse  for  subjecting  a  patient 
to  the  risk  of  conjunctivitis.  If  chloroform  or  ether  is  dropped  into 
the  eye  it  should  immediately  be  washed  out  with  saline  solution. 

If  the  patient  resists  raising  of  the  upper  lid  more  anesthetic 
is  required.  When  the  lid  can  be  raised  without  resistance  the 
reaction  of  the  pupil  to  light  may  be  observed.     The  size  of  the 


722 


GENERAL   ANESTHESIA 


pupil  varies  with  differenl  anesthetics  and  different  stages  of  anes- 
thesia. In  general,  it  may  be  said  that  in  the  beginning  of  an 
anesthetic  it  is  moderately  contracted  or  dilated  and  reacts  to  light ; 
thai  as  anesthesia  grows  deeper  the  pupil  dilates,  but  still  reacts 
to  light ;  and  that  as  anesthesia  reaches  a  dangerous  degree  the 
pupils  are  dilated  and  do  not  react  to  light.  A  preliminary  dose 
of  morphin  contracts  the  pupils,  and  if  it  is  a  large  dose  they  may 
react  very  little,  even  in  light  anesthesia.  Atropin  has  the  oppo- 
site effect  of  giving  these  an  unnatural  dilation,  and  it,  too,  may 
prevent  their  reaction  to  light. 

The  anesthetic  may  stimulate  secretion  of  saliva  and  mucus, 
compelling  the  patient  to  swallow  frequently.  When  the  reflexes  are 

abolished  swallowing  ceases. 
Its  absence  is,  therefore,  one  of 
the  signs  of  surgical  anesthesia. 
The  pain  reflex  may  be 
tested  by  lightly  pinching  the 
patient.  The  operator  gives 
the  best  test  when  he  puts  the 
scalpel  to  the  patient's  skin. 

The  character  of  the  respi- 
ration is  in  itself  a  most  reli- 
able sign  of  the  depth  of  anes- 
thesia. In  a  perfect  surgical 
anesthesia  it  is  deep  and  regu- 
lar, like  a  person  in  a  heavy 
sleep  after  hard  work  or  a 
period  of  excitement.  If  the 
anesthesia  becomes  too  light, 
the  patient  will  sigh  or  respi- 
rations will  become  irregular. 
If  anesthesia  becomes  too  deep, 
respiration  becomes  snoring 
and  all  the  muscles  of  the 
throat  are  absolutely  flabby 
and  without  tone,  or  respiration  may  become  rapid  and  shallow,  or 
respiration  may  cease  entirely.  I  believe  that  a  good  observer  with 
experience  in  the  art  might  be  blindfolded  and  yet  give  a  satisfac- 
tory anesthesia,  being  guided  simply  by  the  sound  of  the  respiration. 


Fig.  408. — Wooden  Wedge  for  Prying 
open  the  Jaw.     Front  and  side  views. 


DISPLACED  JAW 


723 


COMPLICATIONS   DURING   ANESTHESIA 

Compressed  Laps. — Compression  of  the  lips  is  easily  over- 
come by  passing  a  finger  between  them.  If  a  patient  has  no 
teeth  the  jaws  may  close  so  far  that  even  relaxed  lips  become  an 
obstruction  to  respiration. 

Displaced  Jaw. — Sagging  backward  of  the  jaw  and  tongue 
can  be  overcome  by  lifting  the  jaw  forward,  in  this  manner:  First, 
depress  the  chin  to  unlock  the  teeth  if  they  are  in  contact.  Then 
lift  the  jaw  forward  by  pressing  one  or  both  thumbs  under  its 


Fig.  409. — Two  Types  of  Mouth  Gag.  B  is  wedge-shaped  and  can  be  used  to  pry 
open  the  jaw.  The  mouth  must  be  partly  open  before  A  can  be  inserted.  It 
stays  in  place  better  than  B  in  most  cases. 

angles,  the  middle  finger  resting  on  the  bridge  of  the  nose.  When 
it  is  forward  press  it  upward  so  that  the  teeth  may  interlock.  Very 
little  pressure  is  then  required  to  keep  it  in  place,  and  if  the 
patient's  head  is  turned  slightly  to  one  side,  the  jaw  will  prob- 
ably remain  in  good  position  without  being  held.  This  technic 
is   easily  carried  out  on   a   patient  fully   anesthetized.      If  the 


724  GENERAL   ANESTHESIA 

muscles  are  rigid  it  is  much  more  difficult.  It  is  then  usually 
necessary  to  pry  the  teeth  apart  with  a  wedge,  blunt  clamp,  or 
other  instrument,  and  seize  and  draw  forward  the  tongue.  A 
wooden  wedge  is  the  best  instrument  for  prying  open  the  mouth 
(Fig.  408).  It  is  less  likely  to  break  the  teeth  than  a  metal  in- 
strument.. As  soon  as  free  respiration  is  reestablished  and  mus- 
cular spasm  subsides,  the  maneuver  above  mentioned  for  bringing 
the  jaw  forward  can  be  carried  out.  Figure  409  shows  two  styles 
of  gag  for  keeping  the  jaws  apart.  They  require  attention  to  see 
that  they  do  not  slip  off  the  teeth,  especially  if  the  patient  has  lost 
one  or  more  molar  teeth. 

Tongue. — The  tongue  can  be  seized  with  a  gauze  compress, 
or  pierced  with  a  needle  and  thread,  or  pierced  with  a  tongue  for- 
ceps made  like  a  needle  and  flat  ring.  These  things  can  do  no 
serious  injury.  Forceps  which  hold  by  compression,  or  worse  still, 
an  artery  clamp,  may  in  the  excitement  of  the  moment  be  so  firmly 
applied  as  to  nip  a  piece  out  of  the  tongue.  In  cases  proved  to 
be  difficult  it  is  well  to  pass  a  thread  through  the  tongue  in  order 
to  avoid  repeated  attacks  of  suffocation.  Of  course,  no  professional 
anesthetist  will  admit  the  necessity  of  such  a  measure.  Still,  a 
tongue  forceps  should  always  be  at  hand. 

Excitement. — It  was  formerly  customary  to  speak  of  a  stage 
of  excitement  through  which  a  patient  passed  to  reach  the  stage 
of  surgical  anesthesia.  Now  that  anesthetics  are  chemically  purer, 
excitement  is  no  longer  the  rule,  and  is  to  be  classed  rather  as  a 
complication.  Probably  not  one  person  in  a  hundred  laughs  when 
taking  "  laughing  gas,"  as  nitrous  oxid  used  to  be  called.  So,  too, 
when  the  other  anesthetics  are  properly  given  excitement  is  rare, 
being  chiefly  seen  in  alcoholics. 

The  first  cause  for  excitement  is  a  feeling  of  suffocation  due  to 
a  too  concentrated  vapor.  The  remedy  is  a  breath  or  two  of  fresh 
air,  followed  by  a  more  gradual  administration  of  the  anesthetic, 
unless  one  wishes  to  assume  the  responsibility  of  restraining  a 
struggling  patient  and  compelling  him  to  breathe  a  dangerously 
concentrated  vapor.  But  even  though  the  anesthesia  is  given  prop- 
erly, in  a  certain  number  of  cases  excitement  occurs.  These  pa- 
tients, as  has  already  been  stated,  are  chiefly  alcoholics,  and  espe- 
cially well-developed  men,  accustomed  to  give  their  muscles  full 
play — athletes,  longshoremen,  etc.     With  these  patients  a  prelimi- 


VOMITING  725 

nary  dose  of  morphin  is  of  the  greatest  assistance.  If  this  or  some 
similar  drug  is  not  given,  it  is  necessary  to  restrain  the  patient 
and  to  keep  constantly  crowding  the  anesthetic  upon  him  until 
he  succumbs.  This  should  never  be  done  when  his  respiration  is 
impeded  in  any  way.  As  narcosis  deepens  the  excitement  passes 
off,  active  profanity  subsiding  to  some  half-articulate  words  rap- 
idly repeated.  The  anesthetist  then  freshens  or  changes  the  cone 
into  which  the  patient  has  been  violently  spitting,  and  settles  him- 
self for  the  period  of  surgical  anesthesia.  Such  a  patient  should  be 
watched  with  the  greatest  care,  so  that  he  may  not  repeat  the 
fight,  and  the  temptation  is  strong  to  "  soak  it  to  him  "  to  such, 
an  extent  that  he  cannot  possibly  revive  until  long  after  he  has 
been  placed  in  bed.  Such  action  is  a  confession  of  unskillfulness 
on  the  part  of  the  anesthetist  to  which  no  one  who  has  a  real  pride 
in  his  work  will  resort. 

Saliva  in  the  Pharynx. — As  anesthesia  deepens,  swallow- 
ing becomes  imperfect  or  ceases,  and  saliva  collects  in  the  pharynx. 
The  amount  differs  in  different  persons,  with  different  anesthetics 
and  with  different  anesthetists.  If  the  secretion  interferes  with 
respiration  it  should  be  removed.  A  good  instrument  for  the 
purpose  is  a  curved  clamp  seven  inches  long,  holding  a  gauze  swab 
not  larger  than  the  finger.  If  the  patient's  head  is  kept  turned 
to  one  side  the  saliva  will  accumulate  in  the  pouch  of  the  lower 
cheek,  from  which  place  it  is  easily  removed ;  or  it  may  be  drained 
out  by  a  strip  of  gauze.  To  clear  the  pharynx,  however,  it  is  neces- 
sary to  separate  the  jaws  with  a  mouth  gag  and  then  to  pass  the 
sponge  clamp  well  back  over  the  curve  of  the  tongue.  The  saliva 
should  be  swept  to  one  side  and  dragged  out  along  the  cheek.  In 
this  way  a  much  greater  quantity  can  be  extracted  than  by  simply 
passing  the  swab  in  and  out. 

By  a  laboratory  suction  pump  connected  with  a  two-necked 
bottle,  it  is  possible  to  suck  all  blood  and  saliva  from  the  pharynx 
(Fig.  410).  This  device,  long  used  by  dentists,  has  recently  been 
employed  for  tonsillectomy  and  other  operations  on  the  throat  with 
complete  success. 

Vomiting. — Vomiting  in  anesthesia  is  usually  a  sign  of  re- 
turning consciousness  or  the  resumption  of  activity  by  a  set  of 
benumbed  reflexes.  Hence  it  almost  always  occurs  as  the  patient 
passes  from  a  deeper  state  of  anesthesia  to  a  lighter  one.     It  not 


726 


GENERAL   ANESTHESIA 


infrequently  takes  place  from  this  same  cause  in  the  beginning 
of  an  anesthesia  if  the  administration  is  an  uneven  one.  There 
are  occasionally  met  cases  in  which  vomiting  is  induced  by  the 
firsl  smell  of  the  anesthetic;  bul  they  are  very  rare,  and  the  anes- 
thetist will  find  that  as  his  skill  increases  he  will  rarely  see  vomit- 
ing before  the  end  of  an  anesthesia.    If  the  vomited  matter  is  small 


Fig.  410. — Suction  Apparatus  to  Keep  the  Throat  Free  from  Blood  and 
Saliva.  A,  Laboratory  pump  for  attachment  to  faucet;  B,  stiff  rubber  tube 
(?-inch  lead  pipe  may  be  used) ;  C,  bottle  to  receive  the  blood;  D,  ordinary  rubber 
tubing  to  connect  with  E,  soft  rubber  catheters,  which  are  passed  through  the  nos- 
trils to  the  pharynx ;  F,  hard  rubber  or  metallic  tube  for  use  in  the  mouth. 


in  amount  and  of  a  fluid  nature — that  is,  a  mixture  of  water, 
saliva,  mucus,  gastric  juice,  and  bile — the  head  should  be  turned 
to  one  side  and  the  fluid  wiped  away  from  the  mouth  as  the  patient 
expels  it.  The  active  reflexes  in  the  throat  will  prevent  the  fluid 
from  being  drawn  into  the  trachea.  If  blood-clots  or  solid  food 
are  vomited,  the  danger  of  choking  is  greater.     In  snch  a  case  the 


MUSCULAR   SPASMS  727 

anesthetist  should  be  on  the  watch  to  clear  the  patient's  throal  by 
a  clamped  sponge  or  his  finger;  or  it  may  be  necessary  to  invert 
the  patient  to  clear  his  throat  and  enable  him  to  hrealho  freely 
again.  This  is  a  very  good  practice  with  a  child,  whose  light 
weight  enables  one  to  draw  him  quickly  over  the  head  of  the  oper- 
ating table  and  to  support  him  in  a  vertical  inverted  position  for  a 
half  minute  or  until  normal  respiration  is  restored. 

Such  accidents  delay  the  anesthesia,  since  their  careful  treat- 
ment may  bring  the  patient  nearly  back  to  complete  consciousness. 
But  it  is  always  the  safe  rule  to  restore  free  respiration  before  giv- 
ing any  more  of  the  anesthetic.  The  practice,  far  too  common,  of 
looking  on  vomiting  merely  as  an  indication  for  crowding  the  anes- 
thetic is  unwise  and  dangerous. 

There  is  also  a  vomiting  which  precedes  death  on  the  table, 
and  which  is  more  a  pouring  out  of  stomach  contents  through  re- 
laxed passages  than  it  is  a  true  vomiting.  Inversion  is  an  excellent 
practice  in  these  cases,  as  this  position  clears  the  throat,  while  the 
added  flow  of  blood  to  the  brain  may  stimulate  respiratory  move- 
ments. Artificial  respiration  should  then  be  carried  out  for  some 
minutes. 

Muscular  Spasms. — The  muscles  may  undergo  tonic  or  clonic 
contractions  during  anesthesia.  A  patient  with  jaws  set  and  mus- 
cles of  the  throat  firmly  contracted,  making  violent  respiratory 
movements,  but  getting  no  air  into  his  trachea,  and  hence  growing 
blacker  every  second,  is  in  a  dangerous  condition  and  requires  im- 
mediate attention.  The  apparatus  should  invariably  be  removed, 
so  that  the  patient's  first  breath  may  be  pure  air.  The  jaws  should 
then  be  pried  apart  and  the  tongue  brought  forward.  With  a  deep 
sigh  the  air  rushes  into  the  trachea,  cyanosis  disappears  with  two 
or  three  baths,  and  muscular  spasm  subsides.  Possibly  saliva  or 
mucus  may  need  to  be  wiped  from  the  throat.  The  anesthesia 
should  be  resumed  as  soon  as  respiration  is  free  and  deep  cyanosis 
is  gone — that  is,  usually  after  two  or  three  full  breaths  have 
been  taken.  Care  should  be  exercised  to  give  a  less  concen- 
trated vapor,  as  neglect  of  this  precaution  caused  the  muscular 
spasm. 

Clonic  muscular  spasms,  especially  of  the  lower  extremities, 
seen  for  the  most  part  in  alcoholics,  are  not  dangerous,  but  most 
annoying  to  the  surgeon  and  hence  to  the  anesthetist.     A  change 


728  GENERAL   ANESTHESIA 

in  the  position  of  the  patient's  body  may  stop  the  spasms,  but 
usually  it  is  ncirssiry  to  change  the  anesthetic  or  to  push  the  anes- 
thesia to  a  deeper  stage. 

Cyanosis. — Cyanosis  due  to  saliva  in  the  pharynx  and  larynx, 
and  due  to  muscular  spasm  in  the  throat,  is  spoken  of  above.  It 
also  occurs  in  too  deep  narcosis  without,  any  obstruction.  The 
point  at  which  cyanosis  becomes  dangerous  is  different  in  different 
cases.  Nitrous  oxid  especially,  when  administered  without  ad- 
mixture of  air,  may  give  a  deep  cyanosis.  To  a  less  extent  this 
is  true  of  oilier  when  given  by  the  closed  method — thai  is,  when 
the  patient  rebreathes  expired  air  from  a  bag.  Cyanosis  occurring 
withoul  rebreathing  is  more  significant  than  when  some  closed 
form  of  apparatus  is  employed.  Naturally  cyanosis  occurring  in 
a  prolonged  anesthesia  is  more  serious  than  cyanosis  in  a  short 
or  primary  anesthesia ;  but  no  matter  what  the  anesthetic  or 
method  employed,  extreme  cyanosis  is  always  dangerous  and  an 
indication  for  more  air  and  less  anesthetic.  The  change  can  he 
made  gradually  in  most  cases,  but  unless  the  anesthetist  is  expe- 
rienced it  is  well  to  take  no  chances,  but  to  give  the  patient  at 
once  two  or  three  full  breaths  of  pure  air  before  continuing  the 
anesthesia. 

Cessation  of  Respiration. — Sometimes  a  patient  stops 
breathing,  though  there  is  no  obstruction  to  the  respiration.  This 
may  be  due  to  some  form  of  shock  arising  from  extreme  operative 
trauma,  hemorrhage,  prolonged  anesthesia,  or  too  concentrated 
anesthetic  vapor.  There  are,  however,  some  patients  who  simply 
stop  breathing,  although  no  one  of  these  causes  seems  present. 
The  anesthetic  seems  to  abolish  the  respiratory  reflex.  Cessation 
of  respiration  in  this  form  is  evident  early  in  the  anesthesia.  It 
can  usually  be  overcome  by  slapping  the  patient's  chest,  or  by  com- 
pression of  chest  and  abdomen  to  force  out  inspired  air.  If  breath- 
ing is  not  at  once  resumed  the  tongue  should  be  drawn  forward, 
rhythmically  pulled  and  relaxed,  and  artificial  respiration  resorted 
to.  Inversion  or  a  reverse  inclined  position  (Trendelenburg  posi- 
tion )  is  also  helpful. 

Instances  are  recorded  in  which  alternately  inverting  a  patient 
and  then  holding  him  upright  has  overcome  cessation  of  both  res- 
piration and  pulse  from  chloroform.  That  these  extreme  changes 
in  position  have  a  powerful  action  to  promote  the  flow  of  blood 


CESSATION   OF   RESPIRATION 


729 


through  the  heart  and  vessels  is  evident  from  the  changes  in  color 
that  they  produce  on  a  conscious  person  so  treated. 

Ammonia  held  near  the  nostrils  will  powerfully  stimulate  a 
sluggish  respiration.  So  marked  is  its  action  that  if  chloroform 
has  to  be  given  to  a  feeble  person  in  an  emergency,  and  suitable 
apparatus  is  not  at  hand,  it  is  a  good  plan  to  remove  the  cork  from 
a  bottle  of  smelling  salts,  put  a 
gauze  sponge  in  its  neck,  and 
drop  the  chloroform  upon  it. 
The  bottle  then  acts  as  a  holder 
and  the  gauze  can  be  brought 
near  to  the  patient's  lips  with- 
out touching  them,  while  a 
mixture  of  perfumed  ammonia, 
chloroform,  and  air  is  inhaled 
(Fig.  411). 

Briskly  rubbing  the  lips, 
pinching  the  skin,  or  pressing 
on  a  sensory  nerve,  such  as  the 
supraorbital,  are  other  means 
of  stimulation  easily  employed 
by  the  anesthetist,  while  dila- 
tation of  the  sphincter  ani  is  a 
very  powerful  respiratory  stim- 
ulant, which  he  may  request 
the  surgeon  to  employ  in  case  of  necessity.  When  the  patient 
breathes  regularly  the  anesthesia  may  be  resumed:  If  respi- 
ration again  ceases  it  is  well  to  change  the  anesthetic.  Some 
patients,  after  one  or  two  respiratory  failures,  will  breathe  regu- 
larly through  the  whole  operation.  Others  give  so  much  trouble 
that  the  operation  has  to  be  hurried  or  given  up  entirely. 

Cessation  of  respiration  from  one  of  the  forms  of  shock  is,  of 
course,  much  more  difficult  to  overcome.  It  is  not  enough  to  start 
the  patient  breathing;  the  underlying  cause  of  failure  must  be 
properly  handled.  Any  operative  trauma  such  as  rough  handling 
and  pulling  of  intestine  should  be  at  once  discontinued.  The 
effects  of  loss  of  blood  can  be  temporarily  overcome  by  a  reversed 
position  of  the  patient,  by  bandaging  the  extremities  from  their 
tips  toward  the  body,  by  a  large  abdominal  dressing  tightly  ban- 


■  ■■'■■'.  vVV 

1 

i 
i 

i 

1 

: 

1 

1# 

flu      9J 

^S« 

[JALT8 

*«^ 

^■■Jflflfli 

Fig.  411. — Chloroform  may  be  Adminis- 
tered on  Gauze  in  the  Neck  of  a 
Bottle  of  Smelling  Salts. 


730  •  GENERAL  ANESTHESIA 

daged,  by  the  injection  of  a  large  quantity  of  hot  saline  per  rec- 
tum, or  by  hypodermocylsis  or  transfusion.  The  technic  of  these 
measures  is  given  elsewhere.  While  they  cannot  be  carried  out 
by  the  anesthetist,  it  is  his  duty  to  report  the  state  of  the  patient 
to  the  surgeon  and  to  suggest  the  remedy  which  is  best  suited  to 
the  condition  of  the  patient  and  of  the  operating  room.  Any 
reasonable  surgeon  will  welcome  practical  suggestions  of  this  sort, 
especially  if  they  can  lie  carried  out  without  interfering  with  his 
own  work. 

A  saline  enema,  even  though  given  on  the  table,  should  in  case 
of  shock  be  repeated  every  few  hours  until  the  patient's  condition 
is  satisfactory. 

Shock  due  to  prolonged  or  too  concentrated  anesthesia  ought 
not  to  occur.  If  it  does,  the  anesthetist  has  the  remedy  in  his  own 
hands.  If  oxygen  is  available  it  should  be  given  with  the  anes- 
thetic. If  not,  it  is  safe  to  allow  the  patient  who  breathes  badly 
as  a  result  of  shock  to  regain  a  partial  consciousness,  and  there- 
after to  keep  the  stage  of  anesthesia  so  light  that  reflexes  are  not 
entirely  abolished.  Here  again  a  reasonable  surgeon  will  not 
object  to  a  little  restlessness  on  the  part  of  the  patient  if  he  under- 
stands that  it  is  intentional  and  chosen  by  the  anesthetist  to  avoid 
a  more  dangerous  condition. 

Irregular  Heart  Action. — It  is  a  disputed  question  whether 
the  heart  ever  stops-  in  anesthesia  while  respiration  continues.  If 
it  does  it  is  the  exceptional,  not  the  usual  order.  It  often  becomes 
feeble  and  rapid  while  respiration  is  not  greatly  changed.  The 
pulse  is  a  more  sensitive  index  of  shock  than  is  the  respiration. 
Its  tendency  to  become  feeble,  rapid,  or  irregular  gives  the  anes- 
thetist an  early  warning  to  lighten  the  anesthesia  as  much  as  pos- 
sible and  to  be  ready  with  such  stimulating  measures  as  he  thinks 
are  indicated. 

The  hypodermic  injection  of  drugs  to  stimulate  the  heart's 
action  is  far  less  efficacious  than  the  general  measures  enumerated 
above.  But  it  is  a  means  easy  to  use  and  a  syringe  should  al- 
ways be  at  hand.  Digitalin  (gr.  ■%-$),  strychnin  sulphate  (gr. 
^q),  or  a  few  drops  of  adrenalin  chlorid  solution  are  the  best 
drugs  of  this  class.  Their  absorption  in  shock  is  slow,  so  that 
some  time  must  elapse  before  their  maximum  effect  is  shown. 
This  should  be  borne  in  mind  in  determining  a  second  injection. 


RECOVERY   FROM   ANESTHESIA  731 

Amyl  nitrite  and   nitroglycerin  are  contraindicated,   since   they 
dilate  the  vessels. 

Oxygen  in  Anesthesia. — One  of  the  most  useful  controls  of 
anesthesia  is  pure  oxygen  gas.  Its  use  in  anesthetic  mixtures  is 
spoken  of  elsewhere.  Its  use  to  meet  anesthetic  dangers  is  also 
most  important.  It  will  dissipate  cyanosis  more  quickly  than  air. 
It  will  distinctly  improve  pulse  and  respiration  in  shock.  If  given 
after  the  anesthetic  has  been  stopped,  it  hastens  the  return  of  con- 
sciousness. Whenever  possible,  a  can  or  cylinder  of  oxygen  should 
stand  beside  the  anesthetist.  As  occasion  arises  he  can  then  in- 
troduce the  soft-rubber  tube  beneath  the  mask  and  from  time  to 
time  give  a  little  oxygen  as  he  sees  signs  of  respiratory  or  cardiac 
failure.     In  this  manner  serious  symptoms  can  often  be  avoided. 

POST-ANESTHETIC    CONDITIONS 

Recovery  from  Anesthesia. — The  longer  the  duration  of 
anesthesia  the  less  anesthetic  will  be  required  per  minute.  This 
is  chiefly  due  to  the  fact  that  during  inhalation  the  anesthetic 
accumulates  in  the  blood  and  tissues  of  the  body.  Therefore,  a 
constantly  diminishing  quantity  needs  to  be  inhaled  to  keep  the 
blood  saturated. 

If  an  anesthetic  is  skillfully  given  the  patient's  reflexes  will 
act  almost  as  soon  as  the  operator  finishes  his  work.  Even  a  little 
restlessness  during  the  suturing  is  no  serious  disadvantage,  and 
it  shows  that  the  patient  will  make  a  prompt  recovery. 

Elimination  of  the  anesthetic  is  chiefly  through  the  lungs,  so 
that  as  soon  as  the  patient  is  placed  in  bed  he  should  be  given  a 
good  supply  of  fresh  cool  air,  though  protected  from  a  direct 
draught.  This  is  the  more  important  if  the  operation  has  been 
performed  in  the  patient's  room.  A  horizontal  position  on  the 
back  with  no  pillow  or  a  very  thin  one,  is  the  position  of  perfect 
rest  for  most  patients.  But  if  the  character  of  the  operation  does 
not  forbid  motion,  it  is  well  to  let  the  patient  choose  his  own 
position  when  conscious. 

Return  to  consciousness  may  be  hastened  by  inhalation  of  oxy- 
gen. Its  use  is  beneficial  if  there  is  much  shock.  Many  anes- 
thetists apply  hot  wet  towels  to  the  face  for  a  few  minutes  to 
stimulate  respiration  and  hasten  elimination  of  the  anesthetic. 


732  GENERAL   ANESTHESIA 

The  ammonia  funics  in  a  bottle  of  smelling  salts  are  a  powerful 
stimulant  to  respiration. 

It  should  not  be  assumed  that  a  respiratory  stimulant  is  always 
indicated.  If  the  patient  is  returned  to  bed  with  a  good  pulse 
and  quiet,  deep  breathing,  there  is  no  object  in  hastening  the 
return  to  consciousness.  On  the  contrary,  after  an  hour's  sleep 
the  patient  will  awake  to  much  less  discomfort  than  if  suddenly 
revived. 

The  anesthetist  should  always  remain  with  the  patient  until 
the  reflexes  are  well  established.  In  most  cases  if  the  anesthetic 
has  been  skillfully  given,  the  reflexes  are  active  by  the  time  the 
patient  is  put  to  bed,  so  that  this  rule  does  not  entail  much  loss 
of  time.  If  circumstances  permit,  it  is  advisable  for  him  to  re- 
main longer — until  consciousness  has  fully  returned.  He  will 
then  be  able  to  see  the  degree  of  shock,  the  amount  and  character 
of  nausea  and  vomiting,  the  rapidity  of  returning  consciousness, 
and  other  facts  which  will  be  of  great  value  to  him  in  perfecting 
his  anesthetic  technic.  Before  leaving  he  should  tell  the  person 
who  is  left  in  charge  of  the  patient  exactly  what  conditions  to 
expect  and  what  to  do  when  they  arise. 

Nausea  with  Vomiting. — The  most  disagreeable  feature  of 
complete  anesthesia  is  the  nausea  with  vomiting  which  so  often 
follows  it.  Perhaps  one  should  except  the  feeling  of  suifocation 
at  the  beginning  of  an  anesthetic,  but  this  only  exists  when  the 
technic  is  blundering.  It  is  entirely  avoidable;  not  so  the  nausea. 
Skill  in  administration  will  greatly  lessen  it,  but  no  method  has 
yet  been  found  to  avoid  it  altogether.  The  desire  to  do  so  has 
been  the  chief  reason  for  trying  new  anesthetics,  and  new  com- 
binations of  the  old  ones. 

It  is  well  to  keep  in  mind  a  few  facts  concerning  this  nausea. 
Individuals  differ  as  much  in  regard  to  it  as  they  do  in  regard 
to  seasickness,  and  it  is  as  impossible  to  predict  their  suscepti- 
bility in  one  case  as  in  the  other.  This  much  is  certain,  however, 
that  with  a  given  individual  the  possibility  of  post-anesthetic 
nausea  and  vomiting  is  increased  if  an  anesthetic  is  given  when 
the  stomach  is  full  of  food.  It  is  also  increased  if  a  large  amount 
of  the  anesthetic  is  given,  or  if  it  is  given  in  a  concentrated  vapor, 
and  most  markedly  if  it  is  given  irregularly,  so  that  periods  of  con- 
centrated vapor  alternate  with  periods  of  almost  pure  air.    It  also 


SHOCK  733 

seems  probable  that  rebreathing  tends  to  produce  nausea  and  vom- 
iting. Anyone  can  ascertain  the  unpleasant  sensations  caused  in 
a  few  minutes  by  simply  breathing  back  and  forth  into  ;i  closed 
bag.  It  is  reasonable  to  suppose  that  if  this  is  kept  up  for  many 
minutes  the  effect  will  be  much  greater,  and  may  easily  lead  to 
nausea  and  vomiting. 

Quick  or  rough  handling  of  a  patient  coming  out  of  anes- 
thesia will  often  induce  vomiting,  and  ought  to  be  completely 
avoided.  Attempts  to  prevent  vomiting  by  the  use  of  drugs  have 
proved  as  unsuccessful  as  a  similar  treatment  for  seasickness. 
Morphin  given  before  the  anesthesia  has  been  proclaimed  as  a  pre- 
ventive, but  it  certainly  is  not  one.  Inhalation  of  acetic  acid  and 
other  pungent  odors  after  the  anesthesia  are  of  doubtful  value. 
Rather  to  be  recommended  is  the  inhalation  of  oxygen  for  twenty 
minutes  after  chloroform  and  for  an  hour  after  ether. 

Recently  it  has  been  pointed  out  that  the  presence  in  the 
stomach  of  saliva  and  mucus  saturated  with  the  anesthetic  pro- 
motes vomiting,  and  the  claim  has  been  made  that  nausea  and 
vomiting  will  be  prevented  if  the  stomach  is  washed  out  after  an 
anesthesia.  It  is  certainly  true  that  if  the  anesthetic  is  given  in 
such  a  manner  that  there  is  no  such  accumulation  of  vapor-soaked 
fluid  in  the  stomach,  vomiting  is  less  likely  to  occur,  but  this  may 
be  due  entirely  to  the  smaller  quantity  of  anesthetic  and  its  more 
skillful  administration.  It  must  also  be  admitted  that  some  of 
the  worst  cases  of  nausea  and  vomiting  occur  with  an  empty 
stomach  or  are  not  terminated  when  the  stomach  is  emptied. 

If  a  patient  vomits  food  it  is  well  to  pass  a  stomach  tube  and 
wash  out  the  stomach,  so  that  one  may  be  sure  it  is  empty.  Pa- 
tients who  are  troubled  with  continued  nausea  or  repeated  attacks 
of  vomiting  are  often  relieved  by  a  drink  of  hot  water — half  a 
pint  or  more.  This  will  usually  be  vomited  promptly,  and  the 
constant  gagging  will  cease.  Sometimes  it  is  retained,  and  the 
good  effect  is  produced  just  the  same.  Apparently  the  dilution 
of  the  stomach  contents  stops  the  irritation.  A  plan  worth  trying 
with  nervous  patients  is  to  inject  bromide  of  soda,  well  diluted 
with  water,  into  the  rectum  previous  to  the  return  of  consciousness. 

Shock. — The  means  of  combating  shock  have  been  mentioned 
above  under  the  paragraphs  devoted  to  Failure  of  Respiration 
and  Pulse  (p.  728  et  seq.).     Most  of  them  are  as  applicable  to 


734  GENERAL   ANESTHESIA 

shock  after  the  patient  is  in  bed  as  they  are  on  the  table.  A  reverse 
inclined  position  may  be  obtained  by  raising  the  foot  of  the  bed 
on  two  chairs.  This  is  about  as  much  incline  as  is  practical  unless 
some  means  are  used  to  prevent  the  patient  slipping  to  the  head 
of  the  bed.  External  heat  is  a  good  stimulant,  and  may  be  applied 
to  both  the  trunk  and  extremities.  No  leaky  bag  or  bottle  should 
be  used,  and  a  layer  of  blanket  should  always  lie  between  the  hot 
bottle  and  the  patient's  flesh.  This  external  heat  should  not  be 
used  as  a  routine  treatment  irrespective  of  the  patient's  condition. 
It  is  a  very  poor  policy  to  give  a  sweat  bath  to  a  patient  who  is 
free  from  shock  by  surrounding  him  with  hot  bottles  and  wrapping 
him  in  several  blankets.  Yet  this  mistake  is  repeatedly  made 
simply  because  the  treatment  is  part  of  a  routine  intended  to  over- 
come shock.  The  wise  thing  is  to  note  the  condition  of  patient 
and  his  extremities,  and  to  apply  external  heat  and  thick  cover- 
ings only  when  needed. 

Perspiration. — A  cold  perspiration  is  one  of  the  cardinal 
symptoms  of  shock,  and  may  occur  during  or  after  the  anesthesia 
when  shock  is  present.  As  it  causes  an  additional  loss  of  heat 
from  an  already  overtaxed  patient,  it  should  be  looked  upon  as  a 
signal  for  the  application  of  external  heat.  When  the  patient  is 
put  to  bed  the  wet  clothing  should  be  quickly  removed,  the  skin 
dried  by  brisk  friction,  and  a  hot  blanket  wrapped  about  the  body 
and  external  heat  applied.  Atropin  has  a  greater  power  to  check 
excessive  secretion  than  any  other  drug,  but  either  during  the 
anesthesia  or  afterwards  it  should  be  used  only  with  the  full  knowl- 
edge and  consent  of  the  surgeon.  A  satisfactory  dose  is  yto  grain 
of  atropin  sulphate.  If  perspiration  is  profuse,  the  loss  of  fluid 
is  serious  for  the  weakened  patient.  It  is  therefore  well  to  replace 
it  by  injecting  a  pint  of  hot  saline  beneath  the  breast  or  into  the 
flank. 

Death. — Mortality  from  anesthetics  is  underestimated.  The 
truth  of  this  statement  is  becoming  generally  recognized.  Large 
series  of  cases  from  hospitals  in  which  expert  anesthetists  are  em- 
ployed, and  in  which  the  death  rate  from  the  anesthetic  is  usually 
far  below  that  obtained  in  general  practice,  show  that  the  old 
figures  of  one  death  on  the  table  in  10,000  or  20,000  administra- 
tions are  far  too  sanguine.  There  are  few  doctors  who  before  or 
after  their  graduation  have  not  seen  at  least  one  such  death ;  most 


STATUS  LYMPHATICUS  735 

surgeons  have  seen  several.  Yet  10,000  anesthesias  means  three 
every  week  day  for  ten  years,  and  there  are  comparatively  few- 
persons,  even  among  professional  anesthetists,  who  have  had  oppor- 
tunity for  such  extended  observation.  The  immediate  mortality  is 
probably  much  nearer  1  in  1,000  than  1  in  10,000. 

It  is,  however,  the  late  mortality  which  chiefly  escapes  notice. 
Fatalities  due  to  bronchitis  or  pneumonia,  to  persistent  vomiting, 
and  to  suppression  of  urine  and  acetonuria  are  largely  due  to  the 
anesthetic.  When  they  are  counted  and  added  to  the  immediate 
deaths,  the  total  mortality  will  be  surprisingly  large — probably 
nearly  one  per  cent  of  all  patients  who  take  an  anesthetic 
for  half  an  hour  or  longer.  Here  is  a  fertile  field  for  improve- 
ment, but  something  more  is  needed  than  a  mere  count  of  those 
who  die.  We  must  know  the  causes  of  death,  and  perhaps  it  will 
help  even  more  to  know  of  the  narrow  escapes  of  some  of  the 
survivors. 

Death  after  an  operation  is  in  almost  all  instances  due  to  one 
of  these  seven  causes : 

1.  The  anesthetic  (immediate  or  late  death). 

2.  Loss  of  bodily  heat  (one  of  the  contributing  causes  of  pneu- 
monia). 

3.  Operative  trauma  (pulling  nerves,  tearing  tissues,  etc.). 

4.  Hemorrhage  (at  the  operation  or  afterwards). 

5.  Thrombosis,  embolism,  fat  embolism. 

G.  Gross  interference  with  the  function  of  a  vital  organ  (stran- 
gulation of  intestine,  ligation  of  ureter,  etc. ) . 
7.   Infection. 

The  anesthetist  is  concerned  with  the  first  two.  The  mortality 
from  an  anesthetic  may  be  due  to  the  choice  of  a  wrong  anesthetic. 
A  patient  may  succumb  to  chloroform  who  would  survive  ether,  or 
vice  versa.  It  may  be  due  to  a  too  prolonged  anesthesia,  or  to  a 
too  concentrated  vapor,  or  to  both.  That  is,  the  percentage  of  the 
anesthetic  in  the  blood  may  be  fatally  high,  producing  death  from 
suffocation,  or  a  less  percentage  may  be  kept  up  so  long  that  it 
produces  tissue  changes,  which  prove  fatal,  though  possibly  not 
until  several  days  have  elapsed. 

Status  Liymphaticus. — Sudden  death  may  occur  in  a  pa- 
tient having  status  lymphaticus,  no  matter  what  the  anesthetic. 


736  GENERAL  ANESTHESIA 

Such  patients  are   pale,  with  a   pasty   complexion   and   enlarged 

glands,  especially  in  the  neck,  although  these  may  be  obscured  by 
an  excess  of  subcutaneous  fat.  Adenoids  are  often  present,  as 
well  as  enlarged  tonsils,  enlarged  thyroid,  and  a  persistent  thy- 
mus, which  may  be  palpable  above  the  sternum,  and  a  pal- 
pable spleen.  The  blood  pressure  is  low,  as  shown  by  the  pulse, 
by  dilated  pupils,  and  by  flapping  heart  sounds.  Death  may 
occur  very  quickly,  the  only  warning  being  a  few  feeble  res- 
pirations and  a  quickly  failing  pulse.  It  is  thought  by  some  to 
be  due  to  pressure  of  the  large  thymus  on  the  trachea.  Very  little 
anesthetic  should  be  given  such  patients,  and  the  head  should  be 
kept  low. 

Acid  Intoxication. — Much  has  been  written  lately  of  inju- 
rious effects  noticed  some  days  after  the  administration  of  an  anes- 
thetic. They  consist  in  degenerative  changes  in  the  cells,  espe- 
cially of  the  liver  and  kidneys.  In  marked  cases  the  symptoms 
resemble  those  of  acute  yellow  atrophy  of  the  liver,  the  organ  being 
atrophied  and  showing  necrotic  and  fatty  degenerative  changes. 

The  first  symptoms  usually  appear  in  twelve  to  twenty-four 
hours.  They  are  restlessness,  vomiting,  mild  delirium,  slight  jaun- 
dice, a  rapid  pulse,  an  irregular  fever,  and  scanty  urine,  often 
containing  acetone.  In  severe  cases  these  symptoms  increase ; 
breathing  becomes  labored,  cyanosis  and  capillary  hemorrhage  de- 
velop, muscular  spasms  are  added,  the  fever  increases,  and  then 
come  coma  and  death,  generally  in  three  or  four  days  after  opera- 
tion. The  blood  has  a  cherry-red  color,  sometimes  noticeable  be- 
fore death  in  the  area  of  skin  scrubbed  for  operation. 

Various  names  have  been  given  to  post-anesthetic  poisoning. 
Acidosis,  acetonuria,  and  delayed  chloroform  poisoning  are  used, 
as  well  as  acid  intoxication.  This  condition  is  oftener  seen 
after  chloroform,  but  may  also  follow  ether  or  ethyl  chlorid.  It 
is  due  to  a  long-continued  influence  of  the  anesthetic  upon  the  cell 
protoplasm  resulting  not  only  from  a  prolonged  anesthesia,  but 
also  from  a  slow  elimination  after  the  administration  has  ceased. 
Patients  with  anemia,  from  whatever  cause,  septic  patients,  and 
patients  with  disease  of  the  liver  or  biliary  passages,  seem  espe- 
cially prone  to  this  poisoning.  Fat  persons  are  also  said  to  be 
susceptible,  possibly  because  their  tissues  absorb  so  much  chloro- 
form.    The  risk  is  also  greater  when  the  patient  has  been  deprived 


RECORDS  737 

of  carbohydrates  for  some  days  previous  to  the  anesthesia,  ft  is 
well  to  consider  this  before  giving  chloroform  to  a  patienl  who  has 
been  upon  Ochsner  treatment. 

Acidosis  often  yields  to  correct  treatment  if  promptly  given. 
In  fact,  there  are  many  cases  of  post-anesthetic  continued  vomit  ing 
with  scanty  urine  in  which  the  diagnosis  is  not  made,  and  the 
patient  recovers  without  treatment.  One  should  make  it  a  rule 
if  vomiting  continues  for  more  than  twelve  hours  to  wash  out  the 
stomach  with  a  solution  of  bicarbonate  of  soda  and  to  leave  a  few 
ounces  in  the  organ.  If  vomiting  continues  and  other  symptoms 
develop  this  treatment  should  be  repeated  every  few  hours.  In 
addition,  dextrose  or  glucose  should  be  given  by  mouth  or  rectum, 
and  as  soon  as  possible  the  patient  should  take  gruels  and  other 
forms  of  farinaceous  food.  In  a  grave  case  the  patient  should  be 
given  an  intravenous  injection  of  a  quart  of  water  containing  one 
ounce  of  carbonate  of  soda. 

As  a  precautionary  measure,  when  chloroform  is  to  be  given 
to  anemic  or  emaciated  persons  or  those  having  hepatic  disease, 
an  extra  diet  of  carbohydrates  is  recommended  for  a  few  days 
previous  to  operation. 

After  anesthesia  the  air  should  be  fresh  or  mixed  with  oxygen, 
and  respiration  free  to  favor  a  rapid  elimination  of  the  drug. 

Bronchitis  and  Pneumonia. — It  has  long  been  recognized 
that  post-operative  bronchitis  and  pneumonia  may  be  due  to  the 
anesthetic.  The  anesthetist  has  not  done  his  full  share  in  pre- 
venting them  unless  he  warms  the  anesthetic  vapor,  mixes  some 
oxygen  with  it,  uses  the  minimum  quantity,  administers  it  evenly, 
and  protects  the  patient  from  the  loss  of  bodily  heat — for  all  of 
these  things  have  been  shown  to  lessen  the  risk. 

Records. — For  his  own  instruction  and  for  the  education  of 
his  surgeon,  an  anesthetist  should  keep  a  brief  record  of  every 
anesthesia  showing  (1)  the  preliminary  medication,  if  any,  (2) 
the  amount  of  anesthetic  used,  (3)  the  duration  of  its  adminis- 
tration, (4)  the  character  of  recovery  from  the  anesthetic  with  or 
without  nausea,  etc.,  and  (5)  any  unpleasant  symptoms  and  their 
probable  cause.  A  copy  of  this  should  be  given  the  surgeon.  On 
the  next  page  is  a  copy  of  a  card  used  for  this  purpose  by  a  pro- 
fessional anesthetist.  The  data  should  not  be  so  numerous  as  to 
take  too  much  time  for  their  record.     The  amount  of  anesthetic 


738 


GENERAL   ANESTHESIA 


and  duration  of  anesthesia  arc  the   facts  to  fix  in  the  surgeon's 
memory. 


_ — . _^_ 

ANESTHETIC    RECORD 

Name 

Age 

Residence 

Operation 

at 

Performed  by  Dr. 

191 

Hypodermic:   Morphin 

Atropin 

Anesthetic  began 

ended 

Pulse 

Respiration 

Used  Gallons  of  Gas 

;  of  Oxygen                     ; 

Drams  of  Ether 

;  of  Chloroform               ; 

Time  of  Operation 

hr.                          min. 

Remarks: 

M.  D. 

Anesthetist. 

An  anesthetist  cannot  hope  to  choose  intelligently  the  anes- 
thetic best  adapted  to  a  particular  patient,  nor  to  be  able  to  say 
positively  how  much  a  given  patient  can  take  with  safety,  nor  to 
estimate  the  relative  importance  of  different  restorative  measures 
until  he  knows  more  of  the  after-effects  of  the  anesthetic  he  gives. 
How  many  anesthetists,  even  professional  ones,  know  whether  their 
patients  live  or  die  ?  How  rarely  does  one  ever  have  the  chance 
to  obtain  even  at  second  hand,  through  the  nurse  or  doctor,  knowl- 
edge as  to  the  existence  of  symptoms  properly  attributable  to  the 
anesthesia.  Yet  without  such  knowledge  an  anesthetist  can  with 
difficulty  develop  the  technic  and  judgment  which  will  justify  the 
existence  of  his  specialty. 

It  may  be  said  in  opposition  to  this  plan  that  an  anesthetist 
would  have  to  charge  prohibitive  fees  to  justify  such  an  expendi- 
ture of  time.  A  little  calculation  will  disprove  this  idea.  If  an 
anesthetist  can  give  one  anesthesia  at  $10  and  two  at  $5,  six  days 
a  week,  he  will  have  an  annual  gross  income  of  over  $6,000,  and 
after  paying  for  his  anesthetics  and  traveling  expenses  and  a  tele- 


NITROUS   OXID   GAS  739 

phono,  which  is  the  only  office  expense  he  need  have,  there  will 
remain  a  net  income  of  over  $4,000  a  year,  with  plenty  of  spare 
time  to  ascertain  and  record  the  post-operative  symptoms  of  his 
patients.  A  moderate  degree  of  success  in  his  field  will  quickly 
run  his  income  up  to  figures  well  above  those  given.  It  is  clearly 
the  duty  of  the  whole  profession  to  raise  the  standard  of  anes- 
thesia by  encouraging  young  men  to  devote  themselves  to  it  as  a 
specialty;  and,  still  further,  by  giving  those  who  show  aptitude 
for  the  subject  access  to  the  records  kept,  and  opportunity  to  talk 
with  convalescent  patients  and  to  make  such  tests  in  suitable  cases 
as  shall  help  toward  the  solution  of  many  problems. 

ANESTHETICS 

Nitrous  Oxid  Gas. — Nitrous  oxid  gas  was  discovered  by 
Priestly  in  1776,  but  it  was  not  until  1844  that  Wells  demon- 
strated its  anesthetic  power.  It  was  slow  in  coming  into  general 
use.  Its  cost,  the  expensive  and  cumbersome  apparatus  its  adminis- 
tration required,  and  the  skill  necessary  to  obtain  good  results  with 
it,  all  tended  to  delay  its  practical  acceptance  by  the  profession. 
Occasional  attempts  were  made  to  popularize  it,  but  with  no  gen- 
eral effect,  and  its  use  for  many  years  was  almost  entirely  con- 
fined to  dental  offices,  until  the  idea  was  hit  upon  that  it  might 
be  used  to  induce  an  anesthesia,  afterwards  to  be  carried  on  by 
ether.  Within  a  short  time  the  practice  became  widespread,  espe- 
cially in  the  better  hospitals.  It  is  easy  to  put  a  patient  under  gas ; 
it  is  difficult  to  maintain  a  satisfactory  anesthesia  with  it.  More- 
over, the  amount  of  gas  used  for  induction  of  anesthesia  is  so  small 
that  the  cost  is  negligible.  Thus  two  of  the  hindrances  to  its  gen- 
eral use  were  eliminated.  But  even  now,  though  thousands  of 
anesthetists  are  daily  giving  gas  to  induce  anesthesia,  only  a  few 
of  them  use  it  as  the  sole  or  chief  agent  to  produce  an  anesthesia, 
lasting  more  than  a  few  minutes. 

The  technic  of  the  administration  of  gas  for  a  primary  or 
induction  anesthesia  differs  so  much  from  the  technic  of  its  ad- 
ministration for  a  prolonged  anesthesia,  that  their  separate  descrip- 
tion is  advisable.  General  rules  for  the  administration  of  an 
anesthetic  have  been  given  at  the  beginning  of  this  chapter.     They 

should  be  observed  in  the  administration  of  gas. 
49 


740  GENERAL  ANESTHESIA 

Primary  or  Induction  Anesthesia  with  Gas.  —  Apparatus. — Ni- 
trous oxid  gas  is  supplied  in  cylinders  containing  a  hundred  gallons. 
Extra  light  cylinders  can  now  be  obtained  weighing  about  seven 
pounds.  The  gas  weighs  twenty-five  ounces.  As  the  weight  of  the 
cylinder  empty  is  recorded  upon  it,  one  can  always  determine  the 
amount  of  gas  remaining  in  a  partly  used  cylinder  by  weighing 
it  and  subtracting  the  net  weight  of  the  cylinder.  Of  course  the 
scales  must  be  accurate,  as  every  ounce  means  four  gallons  of  gas. 

The  cylinder  is  fitted  with  a  valve  and  a  yoke.  The  latter  con- 
ducts the  escaping  gas  to  a  rubber  tube  which  connects  with  the 
inhaler  (Fig.  412).  The  yoke  must  be  properly  adjusted,  so  that 
its  opening  fits  the  opening  in  the  cylinder,  and  its  bent  tube  leads 
away  from  the  cylinder. 

The  cylinder  may  be  clamped  to  a  table  or  chair,  or  it  may  be 
intrusted  to  an  assistant,  or  the  anesthetist  may  hold  it  between 
his  feet,  or  sit  on  it,  or  place  it  beneath  the  pillow  of  the  patient. 
The  object  is  so  to  fix  the  cylinder  that  the  valve  can  be  easily 
reached  and  turned  with  one  hand.  The  valve  should  always  be 
tested  before  the  inhaler  is  applied  to  the  patient,  to  see  that  it 
works  easily,  and  to  acquaint  the  patient  with  the  noise  of  the 
escaping  gas.  If  the  valve  sticks  so  that  the  gas  does  not  flow 
smoothly,  it  is  well  to  turn  it  quickly  on  and  off,  repeating  this 
motion  until  a  sufficient  amount  of  gas  is  in  the  apparatus.  In 
this  way  the  escaping  gas  is  absolutely  under  control.  If  one 
slowly  releases  a  sticking  valve  the  gas  may  come  out  with  a  rush 
sufficient  to  blow  off  the  rubber  tube  or  burst  the  bag  of  the  appa- 
ratus. If  the  anesthetist  intrusts  the  cylinder  to  an  unskilled 
assistant  he  should  make  him  turn  the  gas  on  and  off  a  few  times 
before  connecting  the  cylinder  with  the  apparatus. 

The  inhaler  consists  of  a  face  piece  which  must  fit  accurately 
over  the  nose  and  mouth,  a  flexible  bag  which  must  hold  at  least 
two  quarts,  and  preferably  four,  and  an  attachment  for  the  rubber 
tube  leading  from  the  cylinder.  This  attachment  must  be  pro- 
vided with  a  stopcock  if  it  is  intended  to  detach  the  inhaler  from 
the  gas  cylinder  before  beginning  the  anesthesia.  If  an  outlet 
valve  is  provided,  a  continuous  supply  of  gas  must  also  be  pro- 
vided ;  otherwise  the  patient  will  make  futile  attempts  to  inhale 
from  a  collapsed  bag,  or,  what  is  more  likely,  he  will  escape  from 
the  anesthesia  by  breathing  air  which  leaks  in  under  the  edge  of 


NITROUS   OXID   GAS 


741 


the  face  piece.  These  are  the  essentials  of  the  apparatus.  If  the 
gas  is  to  be  followed  by  ether  or  chloroform,  souk;  provision  should 
be  made  whereby  the  second  anesthetic  may  be  given  gradually 
while  the  patient  is  still  inhaling  gas;  otherwise  there  may  be  a 
partial,  or  even  a  complete  return  to  consciousness,  as  the  effect 
of  the  gas  disappears  almost  as  soon  as  it  is  withdrawn. 

The  face  piece  must  fit  accurately,  making  everywhere  an 
almost  air-tight  contact.  It  may  be  wholly  of  metal,  its  rim  cut 
irregularly  to  fit  the  nose,  cheeks,  and  chin,  or  it  may  be  of  metal 
and  rubber.  In  the 
latter  case  the  edge  of 
the  metal  part  may  be 
circular  or  oval.  The 
rubber  part  may  be  a 
simple  cylinder  of  soft 
rubber,  the  edge  of 
which  is  cut  to  fit  the 
nose,  or  it  may  be  pro- 
vided with  a  tubular 
edge  which  can  be 
blown  up  and  then 
pressed  against  the 
face.  The  former  de- 
vice is  simpler,  more 
readily  cleansed,  and 
is  equally  efficacious. 

The  face  piece 
should  be  tested  before 
the  gas  is  turned  on. 
If  its  fit  is  faulty,  the 
defect  may  be  reme- 
died by  pressing  its  edge  down  on  a  strip  of  absorbent  cotton 
wrung  out  of  warm  water,  or  after  the  face  piece  has  been  applied 
a  wet  towel  may  be  wrapped  around  its  edge. 

The  patient  must  be  clean  shaven.  It  is  useless  to  try  to  put 
a  man  under  gas  if  any  part  of  the  rim  of  the  face  piece  rests  on 
a  beard.  Enough  air  will  gain  access  to  the  lungs  to  defeat 
narcosis. 

The  bag  which  acts  as  a  reservoir  in  the  usual  dental  appa- 


Fig.  412. — Simple  Apparatus  for  Giving  Nitrous 
Oxid  Gas.  Total  weight,  exclusive  of  cylinder, 
1J€  pounds. 


742  GENERAL    WKSTHESIA 

rains  [s  made  of  rubberized  cloth  or  mackintosh.  If  the  apparatus 
permits  rebreathiug  the  bag  should  be  easy  to  clean.  Hence,  a 
pure  rubber  bag  is  preferable;  A  large  pure  gum  ice  bag,  made 
of  rubber  as  soft  as  surgeon's  gloves,  answers  very  well  and  costs 
thirty  or  forty  cents.  A  small  hole  is  cut  in  it  to  admit  the  stop- 
cock. An  elastic  hand  wrapped  several  times  around  the  two  will 
make  an  air-tight  joint.  This  makes  an  inexpensive  apparatus, 
and  one  which  lakes  up  very  little  space.  Its  total  weight,  exclusive 
of  the  gas  cylinder,  is  one  and  a  quarter  pounds  (Fig.  412).  The 
hitler  and  more  durable  apparatus -used  in  hospitals  and  by  those 
who  make  a  practice  of  anesthetics  weighs  a  little  more. 

To  administer  nitrons  oxid  gas  the  face  piece  is  first  applied 
and  the  gas  turned  on  slowly,  and  then  in  greater  amount  if  neces- 
sary  to  till  the  bag.  There  is  no  spasm  of  the  larynx,  no  cough  nor 
any  hesitation  in  breathing,  since  nitrous  oxid  gas  is  not  at  all 
irritating  to  the  most  sensitive  throat.  After  two  or  three  breaths 
the  patient's  color  changes,  becoming  at  first  more  flushed,  and 
then  somewhat  darker.  If  the  anesthetic  is  continued  without 
admixture  of  air  or  oxygen,  this  cyanosis  increases  until  the  patient 
becomes  a  dark  blue,  and  then  almost  black,  or  a  sickly,  lead  color 
as  respiration  ceases. 

Respiration  from  the  start  is  deepened  and  accelerated,  and 
may  become  panting  as  the  patient  feels  the  lack  of  oxygen.  If 
the  anesthetic  is  pushed  further,  respiration  often  ceases  rather 
suddenly.  The  heart  is  at  first  stimulated  and  the  pulse  is  full 
and  rapid.  The  rapidity  increases  with  an  increase  of  the  gas, 
but  if  a  dangerous  amount  is  given  the  pulse  slows  and  may  become 
imperceptible. 

The  pupils  dilate  widely  even  with  a  safe  amount  of  gas. 
In  a  dangerously  deep  anesthesia  they  are  still  more  widely 
dilated.  The  eyelids  may  stand  open,  showing  the  eyes  rolled 
upward. 

Complete  anesthesia  may  be  obtained  with  five  or  ten  breaths 
of  nitrous  oxid  gas,  especially  if  there  is  some  rebreathing,  or  the 
patient  may  continue  to  breathe  it  for  many  minutes  without  los- 
ing consciousness.  Half  a  minute  to  two  minutes  may  be  given 
as  fair  limits  to  the  production  of  unconsciousness.  If  an  effect 
is  not  produced  promptly  there  is  reason  to  suspect  the  apparatus. 
It  probably  does  not  fit  the  face  accurately,  or  the  bag  holding  the 


NITROUS  OXID   GAS  743 

gas  is  too  small  to  permit  a  full  inhalation  of  gas  alone,  or  there 
is  a  leak  in  the  apparatus. 

There  are,  however,  muscular  and  alcoholic  subjects  who  are 
put  under  gas  only  with  great  difficulty  or  not  at  all.  A  prelimi- 
nary dose  of  morphin  or  other  narcotic  (see  p.  71!))  is  advised  by 
many  anesthetists  in  all  cases,  and  is  usually  insisted  on  in  mus- 
cular and  alcoholic  cases. 

If  the  gas  anesthesia  is  a  primary  one,  the  removal  of  the 
inhaler  permits  the  patient  to  breathe  pure  air.  Consciousness 
usually  returns  as  soon  as  a  few  breaths  are  taken,  though  it  may 
be  delayed  for  a  minute  or  two.  There  is  rarely  any  nausea  or 
headache.  There  may  be  dizziness  or  uncertain  mental  action  for 
a  few  minutes.  The  accelerated  respiration  of  the  anesthesia  is 
automatically  continued  for  a  few  moments,  and  materially  hastens 
a  return  to  consciousness. 

Contraindications  for  the  use  of  gas  to  induce  anesthesia  as 
for  brief  operations  are  confined  to  the  existence  of  obstructions 
to  respiration,  such  as  an  abscess  in  the  throat,  an  obstruction  in 
the  larynx,  a  large  thymus  or  tumor  pressing  on  the  trachea,  etc. 
These  things  need  only  be  regarded  as  contraindications  if  they 
are  extreme  enough  to  seriously  embarrass  respiration,  but  any 
patient  with  swelling  of  the  mouth  or  throat  should  be  carefully 
observed  every  minute  of  a  gas  anesthesia. 

Danger  from  gas  is  due  to  an  overdose.  The  patient  becomes 
cyanotic  and  then  ceases  to  breathe.  Removal  of  the  apparatus, 
combined  with  artificial  respiration  if  need  be,  will  revive  the 
patient.  It  is  a  mistake  to  think  of  gas  as  absolutely  safe.  A 
number  of  deaths  from  its  use  have  been  recorded. 

Nitrous  Oxid  Gas  for  Prolonged  Anesthesia — If  prolonged  anes- 
thesia is  desired,  it  is  necessary  to  allow  the  patient  to  breathe 
some  air  or  else  to  mix  oxygen  with  the  gas,  for  if  gas  only  be 
given  the  patient  becomes  cyanotic  in  a  few  minutes  and  then 
ceases  to  breathe.  If  a  few  breaths  of  air  are  allowed  the  gas  can 
be  given  again  with  safety.  This  method  of  alternating  gas  and 
air  is  unsatisfactory,  since  it  is  likely  to  produce  a  struggling 
patient.  Moreover,  it  is  not  free  from  danger.  A  better  plan  is 
to  allow  the  patient  a  little  air  by  slightly  raising  one  edge  of  the 
face  piece,  or  by  opening  the  air  valve,  if  the  apparatus  is  pro- 
vided with  one.     A  very  little  air  is  sufficient  to  keep  the  patient 


744  GENERAL   ANESTHESIA 

breathing  regularly  and  r.»  ward  off  deep  cyanosis.  If  much  air 
is  allowed  anesthesia  is  interrupted,  and  the  patient  becomes  rest- 
less and  may  retch  or  even  vomit.  This  method  requires  the 
closest  observation  on  the  part  of  the  anesthetist,  but  a  little  prac- 
tice will  enable  any  observing  person  to  administer  gas  in  this 
way  for  half  an  hour  or  more,  keeping  most  patients  more  or  less 
constantly  in  the  stage  of  surgical  anesthesia.  There  will  be  some 
cyanosis  and  the  blood  will  be  darker  than  it  is  in  a  safe  stage 
of  chloroform  or  ether  anesthesia.  The  amount  of  gas  used  will 
vary  with  different  patients  and  different  anesthetists  from  150 
to  300  gallons  per  hour.  There  are  some  patients  who  cannot 
be  satisfactorily  anesthetized  with  gas  and  air. 

Oxygen  mixed  with  gas  gives  a  far  better  anesthesia  than  when 
air  is  admitted.  The  amount  of  oxygen  required  is  much  less  than 
the  amount  of  air,  and  hence  the  patient  may  get,  if  necessary, 
a  higher  percentage  of  gas  in  each  inhalation.  The  anesthesia  is 
better  maintained  and  with  less  cyanosis  when  oxygen  is  employed. 
It  has  been  found  that  the  gas  at  the  time  of  inhalation  should 
contain  from  sixteen  to  twenty-two  per  cent  of  air,  or  from  ten  to 
twenty  per  cent  of  oxygen.  Even  less  oxygen  will  prevent  cya- 
nosis. The  greater  quantity  is  often  needed  to  avoid  a  too  deep 
anesthesia.  If  oxygen  is  used  in  this  manner,  from  twenty  to 
forty  gallons  are  consumed  per  hour. 

If  the  gas  and  air,  or  oxygen,  are  inhaled  at  the  body  tem- 
perature, they  are  more  quickly  taken  up  by  the  blood  and  there 
is  less  loss  by  exhalation.  In  this  way  there  is  a  saving  of  about 
one  third  of  the  gas  and  oxygen  employed.  A  greater  economy  is 
effected  by  permitting  a  certain  amount  of  rebreathing.  Gatch 
has  arranged  an  apparatus  by  which  rebreathing  in  periods  of  two 
minutes  is  easily  carried  out.  The  resulting  cyanosis  is  so  slight 
as  to  do  the  patient  no  harm.  In  fact,  it  is  said  to  improve  his 
condition  by  keeping  up  blood  pressure. 

Gas-oxygen  is  not  suited  to  prolonged  operations  about  the 
mouth.  In  cases  of  respiratory  difficulty  and  of  high  blood  pres- 
sure, any  form  of  anesthesia  which  produces  cyanosis  should  be 
avoided.  With  these  exceptions  there  are  no  contraindications  to 
gas  with  oxygen,  which  gives  beyond  doubt  the  safest  anesthesia 
known.  Still,  one  fatality  at  least  has  been  reported  from  its  use. 
!No  anesthetist  has  mastered  his  art  until  he  has  learned  to  give 


NITROUS  OXID  GAS 


745 


it  perfectly.    And  when  he  has  done  so  he  will  have  little  difficulty 
in  winning  surgeons  and  patients  to  its  use. 

Apparatus. — The  usual  form  of  gas  apparatus  can  be  used 
for  giving  gas  and  oxygen  by  connecting  both  cylinders  with  the 


Fig.  413. — Gwathmey's  Apparatus  for  Giving  Warmed  Nitrous  Oxid  Gas  and 
Oxygen.  A,  Gas  cylinder,  showing  coil,  D;  B,  gas  cylinder,  showing  cup,  E,  for 
hot  water;  C,  oxygen  cylinder;  F,  inhaler  with  valve  to  show  percentage  of  gas 
and  oxygen  given,  and  other  valves  to  admit  air. 

inhaler  by  means  of  a  Y  tube.  It  is  better  to  carry  the  Y  up 
close  to  the  inhaler,  having  a  separate  bag  for  the  gas  and  for  the 
oxygen.     In  Gwathmey's  apparatus  a  valve  shows  approximately 


746 


GENERAL  ANESTHESIA 


ike  percentages  of  gas  and  oxygen  given.  In  (his  apparatus  pro- 
vision is  made  for  heating  the  gas.  As  the  gas  escapes  from  the 
cylinder  it  passes  through  a  metallic  coil,  immersed  in  hot  water 
held  in  a  cup,  lifted  to  the  top  of  the  cylinder  (Fig.  413). 

A   more  elaborate  apparatus  has  loeen  devised  by  Teter,  and 
extensively    used    by   him    and   others    (Fig.    414).     This   appa- 


Fig.  414. — Gas-oxygen  Apparatus  with  Attachments  for  Four  Cylinders  on 
a  Foot  Plate.  A,  Inhaler;  B,  tank  for  warming  the  gases;  C,  attachment  for 
dropping  ether  into  the  stream  of  gas  and  oxygen;  D,  attachment  for  giving  ether 
vapor.     (Teter's  apparatus  as  modified  by  Coburn.) 


ratus  looks  cumbersome,  but  one  should  not  be  frightened  by  its 
appearance.  Its  weight  without  cylinders  is  sixteen  pounds. 
It  can  be  used  with  a  stand,  but  if  provided  with  a  foot  plate 
it  will  stand  on  a  chair,  and  then  it  will  pack  into  an  ordinary 
suit  case.  Its  advantages  are  very  real  and  far  outweigh  its 
pounds  avoirdupois.  The  cylinders  are  fixed  so  that  they  need 
never  be  held  while  the  valves  are  turned.  Either  gas  or  oxygen 
or  any  mixture  of  the  two,  is  delivered  warm.  A  little  ether  vapor 
may  be  added  if  the  patient  is  restless  or  if  muscular  relaxation 


NITROUS   OX  ID   (J  AS  747 

is  not  complete.  It  is  astonishing  what  a  lasting  effect  a  single 
dram  of  ether  will  have  when  used  in  this  combination.  Pure 
oxygen  is  constantly  at  hand  to  revive  the  patient  if  he  shows 
signs  of  collapse,  or  at  the  close  of  the  anesthesia. 

Complications  and  Dangers. — There  are  only  two  compli- 
cations peculiar  to  gas-air  and  gas-oxygen  anesthesia.  One  is  a 
failure  to  secure  sufficiently  deep  anesthesia.  This  is  due  usually 
to  lack  of  practice.  The  addition  of  a  small  amount  of  ether 
vapor  will  correct  this.  Most  forms  of  apparatus  provide  for  the 
administration  of  a  little  ether  while  the  patient  is  breathing  the 
gas.  If  the  apparatus  does  not  provide  for  this,  the  gas  inhaler 
may  be  removed  and  the  ether  or  chloroform  inhaler  substituted, 
and  after  a  few  breaths  the  gas  inhaler  may  be  replaced.  A 
preliminary  injection  of  morphin  lessens  the  frequency  of  this 
emergency. 

The  other  complication  is  the  development  of  extreme  cya- 
nosis. The  best  remedies  are  always  at  hand,  namely,  oxygen  or 
air.  The  gas  should  be  reduced  or  discontinued  and  the  percent- 
age of  oxygen  increased  until  the  color  and  respirations  are  again 
good.  It  should  be  understood  that  there  is  apt  to  be  more  cya- 
nosis with  gas  and  air  than  with  gas  and  oxygen,  on  account  of 
the  fact  that  the  high  percentage  of  gas  required  for  anesthesia 
(80  to  90  per  cent)  does  not  always  leave  room  enough  for  suf- 
ficient air  to  oxygenate  the  blood.  Ten  per  cent  of  air  will  not 
do  this,  while  10  per  cent  of  oxygen  will.  If  the  patient  can  be 
anesthetized  with  80  per  cent  of  gas  there  will  be  no  cyanosis  in 
either  case.  If  the  apparatus  does  not  permit  the  percentage  of 
gas  administered  to  be  varied  at  will,  cyanosis  can  be  overcome 
by  allowing  a  little  air — a  very  little  air — to  leak  in  around  the 
face  piece.  This  should  never  be  attempted  until  the  patient  is 
well  under  the  gas. 

Other  accidents  arising  during  gas-air  or  gas-oxygen  anesthesia 
are  almost  unknown.  If  any  should  arise  they  should  be  met  by 
the  precautions  given  at  the  beginning  of  this  chapter. 

As  far  as  known  there  are  no  serious  post-anesthetic  complica- 
tions attributable  to  nitrous  oxid  gas.  Animals  have  been  anes- 
thetized with  it  for  days,  and  have  apparently  suffered  no  perma- 
nent injury.  While  one  hesitates  to  compare  results  obtained  in 
healthy  animals  with  those  observed  in  sick  men,  clinical  observa- 


748  GENERAL  ANESTHESIA 

tion  thus  far  shows  no  serious  after  effects  of  prolonged  gas  anes- 
thesia. Headache  and  nausea  and  vomiting  may  continue  for  an 
hour  or  two  after  the  anesthesia,  but  there  seem  to  be  no  paren- 
chymatous changes  in  the  vital  organs,  such  as  are  frequently 
found  after  ether  and  chloroform. 

Ether. — The  intoxicating  properties  of  sulphuric  ether  were 
known  some  time  before  its  anesthetic  possibilities  were  recog- 
nized. College  students  and  others  often  inhaled  it  to  experience 
its  exhilarating  effects.  It  was  also  known  to  many  that  those 
under  its  influence  were  more  or  less  insensitive  to  pain,  but  the 
vast  import  of  this  fact  was  not  recognized.  Hence  the  difficulty 
in  determining  who  is  the  real  discoverer  of  anesthesia.  Long, 
Wells,  Morton,  Marcy,  and  Jackson  all  claimed  the  honor.  Long 
has  the  distinct  advantage  of  an  entry  in  his  ledger,  date  of  March 
30,  1S42,  showing  that  he  gave  ether  for  the  removal  of  a  small 
tumor,  charging  two  dollars  for  anesthetic  and  operation.  In  1844 
Wells,  acting  on  a  suggestion  by  Marcy,  gave  ether  successfully 
for  extraction  of  a  tooth.  Neither  he  nor  Marcy  knew  of  Long's 
previous  use  of  it  in  surgery.  In  1846  Morton  gave  ether  for  a 
surgical  operation,  at  Jackson's  suggestion,  so  it  is  claimed.  Let 
him  who  will  weigh  the  deserts  of  the  claimants  and  apportion  the 
honor.  Within  a  few  years  the  use  of  ether  was  known  in  all 
civilized  countries,  but  its  general  adoption  was  seriously  checked 
by  the  discovery  of  chloroform  in  1847.  This  is  not  the  place 
to  review  the  history  of  the  struggle  for  the  mastery  between 
these  two  anesthetics — a  struggle  which  has  lasted  half  a  cen- 
tury and  has  not  yet  come  to  an  end.  Their  respective  merits 
are  set  forth  in  the  section  on  the  choice  of  an  anesthetic  on 
page  767. 

Ether  is  the  commonest  anesthetic,  at  least,  in  America,  and 
its  use  is  on  the  increase  in  Europe.  It  is  beyond  doubt  the  most 
satisfactory  anesthetic  for  the  unskilled  administrator.  He  is  able 
to  anesthetize  all  patients  with  it  and  few  will  die  on  the  table. 
This  is  not  to  say  that  skill  is  wasted  in  the  administration  of 
ether.  On  the  contrary,  this  anesthetic  offers  a  splendid  field  for 
exact  administration,  but  the  other  anesthetics  simply  cannot  be 
given  satisfactorily  except  with  a  certain  amount  of  skill.  Hence, 
as  long  as  there  are  unskilled  anesthetists,  ether  will  hold  an  un- 
disputed place. 


ETHER  749 

Symptoms  of  Ether  Anesthesia. — Ether  vapor,  especially 
when  cold,  is  irritating  to  many  persons.  Some  of  them  are  nau- 
seated by  its  odor,  but  this  is  less  noticeable  with  a  pure,  product 
than  with  an  impure  one.  It  stimulates  the  secretion  of  mucus 
and  saliva,  and  if  too  concentrated  excites  coughing  and  laryngeal 
spasm.  Many  male  patients  spit  violently  into  the  inhaler  as  soon 
as  their  sense  of  propriety  is  somewhat  dulled.  Others  expe- 
rience a  feeling  of  suffocation  and  attempt  to  pull  the  cone  from 
the  face,  or  to  turn  the  head  aside  so  as  to  breathe  pure  air.  Still 
other  patients  retch  and  many  vomit  in  the  beginning  of  the  anes- 
thetic. These  symptoms  are  much  less  likely  to  occur  if  the  vapor 
is  given  steadily,  but  without  much  concentration  at  first.  They 
are  also  less  marked  if  a  warmed  vapor  is  used.  They  are  usu- 
ally absent  when  the  administration  is  skilled. 

Commencing  Anesthesia. — The  normal  symptoms  observed  be- 
fore the  stage  of  surgical  anesthesia  is  reached  are  a  flushed  face, 
deepened  respiration,  a  quickened  pulse,  and  a  slight  moisture  of 
the  skin.  There  may  be  a  little  rigidity  of  the  muscles  which  soon 
passes  off  as  the  anesthesia  deepens  and  gives  place  to  an  increas- 
ing placidity.  The  occurrence  of  excessive  rigidity  and  clonic  con- 
tractions is  a  state  which  is  commonly  seen  in  alcoholics.  It  is  rare 
with  other  patients  unless  the  administration  is  very  irregular.  It 
passes  off  as  more  ether  is  given.  Blood  pressure  is  slightly  raised  at 
first,  but  prolonged  etherization  greatly  lowers  the  blood  pressure. 

The  pupils  may  be  dilated  or  contracted.  If  dilated  they  will 
react  to  light.  A  preliminary  dose  of  morphin  will  have  the  effect 
of  making  the  pupil  smaller.  The  corneal  reflex  is  maintained 
and  is  shown  by  a  tightening  of  the  eyelids  when  one  attempts  to 
lift  the  upper  lid.  The  lining  of  the  lid  and  the  eyeball  should 
never  be  touched  with  the  finger. 

Excitement  is  far  less  common  now  that  pure  ether  is  generally 
employed.  With  an  even  administration  it  is  absent  or  of  slight 
degree  except  in  neurotic  or  alcoholic  subjects.  But  even  the  quiet- 
est patient,  if  unrestrained,  should  be  closely  watched  until  sur- 
gical anesthesia  is  reached,  for  occasionally  a  patient  hitherto 
absolutely  quiet  will  strike  away  the  inhaler  and  spring  to  a  sit- 
ting posture  in  perfect  delirium. 

Surgical  Anesthesia.— The  signs  of  surgical  anesthesia  have 
been  given  on  page  721.     When  ether  is  the  agent  the  pupils  are 


750  GENERAL   ANESTHESIA 

moderately   dilated   bu1    react    to  light;   the  eyelid   closes  slowly 

when  raised  and  released;  the  eyes  often  roll  slowly  from  side  to 
side;  the  arm  is  limp;  respiration  is  regular  at  a  normal  rate  or 
a  little  increased,  and  there  may  lie  a  light  snoring;  the  pulse,  which 
may  have  risen  to  over  100,  falls  to  90  or  80,  or  even  lower ;  the 
skin  is  pink  and  slightly  moist;  when  the  skin  is  pinched  the 
patient  does  not  move.  This  degree  of  surgical  anesthesia  is 
readied  in  seven  to  fifteen  or  mure  minutes  if  ether  alone  is  given. 
One  t<>  three  ounces  of  ether  are  required  for  the  purpose.  From 
this  point  on  less  anesthetic  is  necessary,  three  ounces  an  hour 
being  sufficient  when  carefully  given. 

Danger  Signals. — Signs  of  too  deep  anesthesia  from  ether  are 
absolutely  flabby  muscles,  shown  by  eyelids  remaining  open  when 
separated,  lips  loose  or  blowing  in  and  out  with  respiration,  dilated 
pupils  not  reacting  to  light,  a  deep  respiration  possibly  with  heavy 
snoring,  or  a  light  irregular  respiration  with  pale  skin,  or  other 
symptoms  of  shock.  The  treatment  is  to  stop  the  ether,  give 
oxygen,  and  perform  artificial  respiration  if  the  patient  fails  to 
breathe.  !STo  more  ether  should  be  given  until  muscular  tone  is 
restored,  and  then  only  in  limited  amount.  The  various  accidents 
of  anesthesia  common  to  ether  and  other  agents  are  described,  and 
remedies  given  on  pages  723  to  731. 

Methods  of  Administering  Ether. — Ether  may  be  given 
by  inhalation  in  three  ways :  ( 1 )  by  the  open  method,  ( 2 )  by  the 
closed  method,  and  (3)  by  the  vapor  method. 

1.  The  Open  Method. — Ether  is  poured  or  dropped  on  a  layer 
of  pervious  material,  such  as  a  sponge,  gauze,  or  cotton,  held  at  a 
little  distance  from  the  mouth  or  nose.  Light  layers  of  gauze  may 
be  laid  across  the  face,  or  spread  on  a  wire  mask,  or  arranged  in 
a  cone  which  is  freely  open  at  the  top  and  which  may  be  of  home 
construction,  from  paper  or  pasteboard  and  a  towel,  or  it  may  be 
of  metal  with  a  rubber  face  piece. 

The  apparatus  should  be  so  constructed  that  its  permanent 
parts  are  easily  cleaned,  and  the  gauze  easily  changed.  The  care- 
less practice  of  using  a  cone  over  and  over  again  without  renewing 
or  sterilizing  such  parts  as  a  patient  breathes  upon  merits  severe 
condemnation. 

When  ether  is  given  by  the  open  method  there  is  said  to  be  no 
rebreathing  of  expired  air.     This  is  relatively  but  not  absolutely 


ETHER 


751 


true,  for  the  portion  of  expired  air  lying  between  the  ether-soaked 
gauze  and  the  nose  or  mouth  is  always  febreathed.  In  some  forms 
of  apparatus  this  amounts  to  several  cubic  inches,  but  it.  is  usually 
mixed  with  a  much  larger  quantity  of  fresh  air,  which  streams 
through  the  gauze  or  leaks  under  the  face  piece  during  inspiration. 
Its  effect  is,  therefore,  negligible.  The  inspired  air  is  always 
very  cold,  having  given  up  its  heat  to  vaporize  the  liquid  ether 
placed  on  the  gauze. 

2.  The  Closed  Method. — The  ether  is  poured  on  a  pervious 
material  which  is  contained  in  a  cylinder  or  other  form  of  appa- 


Fig.  415. — Apparatus  for  Giving  Gas  and  Ether  or  Ether  by  the  Closed  or 
Open  Method.  A,  Inhaler;  B,  outlet  valve;  C,  reservoir  containing  gauze  to  be 
saturated  with  ether;  D,  valve  to  regulate  mixture  of  gas  and  ether;  E,  valve  to 
admit  air;  F,  bag  for  gas,  or  to  permit  re  breathing.     (Gwathmey.) 

ratus  open  only  at  its  ends.  One  end  is  made  to  fit  closely  to' 
the  face,  usually  by  means  of  a  rubber  ring,  while  the  other  fits 
into  a  soft-rubber  bag  large  enough  to  hold  without  pressure  the 
whole  expired  breath  (Fig.  415).  The  patient  breathes  back  and 
forth  into  the  bag,  each  inspired  breath  passing  the  ether  dia- 


752  GENERAL   ANESTHESIA 

phragm  twice — once  in  the  previous  expiration  and  once  in  the 
inspiration.  The  percentages  of  ether  and  of  carbon  dioxid  may 
easily  become  high  under  the  circumstances.  The  inspired  air 
is  always  warm  and  may  have  almosl  the  temperature  of  the 
body  as  it  passes  back  and  forth,  with  little  chance  to  lose  the 
heat,  which  is  renewed  each  time  it  is  breathed.  Rehroathing 
produces  a  certain  amount  of  cyanosis.  It  is  obvious  that  perfect 
rebreathing  would  soon  lead  to  a  dangerous  cyanosis.  Hence,  if 
the  apparatus  does  not  leak  anywhere  a  little  fresh  air  must  be 
admitted  either  by  inlet  and  outlet  valves  or  under  the  edge  of 
the  face  piece.  The  blood  pressure  is  varied  even  more  than 
when  ether  is  given  by  the  open  method,  on  account  of  cya- 
nosis, but  this  rise  is  soon  followed  by  a  fall  as  anesthesia 
continues. 

3.  The  Vapor  Method. — Air  is  pumped  through  a  modified 
Wolff  bottle  containing  ether.  It  takes  up  a  varying  amount  of 
ether,  according  to  the  depth  of  the  fluid  through  which  it  bubbles. 
The  amount  is  rarely  over  six  per  cent.  It  is  then  pumped  through 
a  second  bottle  containing  warm  water,  and  then  passes  into  the 
inhaler,  or  it  may  be  conducted  directly  into  the  mouth  or  nose. 
If  the  water  in  the  wash  bottle  is  too  hot  it  unduly  rarefies  the 
ether.  A  good  temperature  is  100°  F.  As  it  is  cooled  rapidly  the 
water  should  be  renewed  every  half  hour  or  so,  according  to  the 
size  of  the  bottle. 

As  it  is  difficult  to  keep  many  patients  anesthetized  with  ether 
alone  by  the  vapor  method,  the  apparatus  should  also  provide  for 
the  addition  of  chloroform  vapor  from  time  to  time  (Fig.  417, 
p.  757). 

The  percentage  of  ether  vapor  taken  up  by  the  air  which  bub- 
bles through  it  may  be  increased  by  using  a  deep  bottle  and  a 
larger  quantity  of  liquid  ether.  This  makes  the  apparatus  cumber- 
some and  adds  to  the  expense  by  leaving  a  large  quantity  of  unused 
ether  at  the  close  of  the  operation.  An  ingenious  device  of  Sutton 
compels  the  air  bubbles  to  travel  slowly  around  a  spiral  tube  im- 
mersed in  the  ether  bottle.  Thus  the  percentage  of  ether  in  the 
inspired  air  is  greatly  increased,  although  the  bottle  is  only  filled 
with  ether  to  the  depth  of  an  inch  or  two. 

The  good  and  bad  points  of  these  three  methods  of  adminis- 
tration may  be  seen  by  a  glance  at  the  following  table: 


ETHER 


753 


Amount  of  ether  inhaled 

Amount  of  ether 
wasted* 

Temperature  of  inhaled 
vapor 

Amount  of  fresh  air  in- 
haled  

Cost  of  apparatus 

Approximate  cost  of 
ether  per  hour 

Secretion  of  mucus  and 
saliva 

Post-anesthetic  nausea 
and  vomiting 

Post-operative  bronchi- 
tis and  pneumonia .  . 

Difficulty  with  ath- 
letes, alcoholics  and 
drug  habitues 


Open  Method. 


Unknown — varies 
greatly 

Large 

Cold 

Ample 


4  oz.  $.36 
Considerable* 

More  or  lessf 

Some 

Considerable 


Closed  Method. 


Known — variations 
slight 

None 

Warm 

Scanty 

$6.— $48. 

3  oz.  $.27 
Considerable! 

More  or  lessf 


Less  than  by  open 
method 


Less  than  by  open 
method 


Vai'Oh  Method. 


Known — constant 

None 
Warm 
Ample 
$9.— $50 

2  oz.  $.18 

Less  than  by  other 
methods 

Less  than  by  other 
methods 

Least 


More      than      by 
other  methods 


*  This  does  not  refer  to  ether  remaining  in  can  or  bottle  at  the  close  of  the 
operation.     It  means  the  waste  by  evaporation  in  the  room. 

t  Advocates  of  the  open  method  and  the  closed  method  each  claim  a  reduced 
amount  of  secretion  of  mucus  and  saliva.  As  swallowing  of  ether-soaked  fluids 
is  one  of  the  causes  of  vomiting,  it  is  of  importance  that  such  secretion  be  kept 
at  a  minimum. 

J  On  this  point  the  claims  of  the  advocates  of  the  first  two  methods  differ 
widely.  The  truth  is  that  although  the  methods  differ  a  good  deal  the  skill  of 
different  anesthetists  differs  a  great  deal  more.  Some  men  will  keep  their  com- 
plications and  after  effects  at  a  low  figure  no  matter  what  method  they  use, 
while  others  are  constantly  getting  their  patients  into  trouble. 


McRoberts  has  an  ingenious  plan  so  that,  while  giving  ether 
by  the  open  method,  he  warms  the  vapor  before  the  patient  in- 
hales it.  He  fixes  an  electric  light  bulb  (16  candle  power)  in  an 
Allis  inhaler,  covers  it  with  several  layers  of  gauze,  turns  on  the 
current,  and  drops  ether  on  the  gauze.  It  is  rapidly  volatilized 
and  warmed  by  the  light.  The  secretion  of  mucus  and  saliva  is 
not  stimulated  as  when  a  cold  vapor  is  inspired.  Much  less  ether 
is  required  than  by  the  usual  open  method. 

Gas-Ether  Sequence. — The  induction  of  anesthesia  with  ni- 
trous oxid  gas  and  its  continuation  with  ether  is  spoken  of  as 


754  GENERAL   ANESTHESIA 

gas-ether  sequence.  The  initial  narcosis  with  gas  saves  the  patient 
from  the  smell  of  ether,  and  preliminary  struggling,  choking,  and 
vomiting  are  avoided.  The  period  of  induction  is  one  to  four 
minutes  instead  of  ten  to  fifteen  minutes  when  ether  alone  is  em- 
ployed. These  advantages  are  so  marked  that  everyone  who  gives 
anesthetics  should  provide  himself  with  the  necessary  apparatus. 
There  are  some  patients,  chiefly  children,  who  are  frightened  by 
the  inhaler  and  noise  of  the  gas.  This  may  be  urged  as  an  objec- 
tion to  the  use  of  gas,  but  most  of  those  patients  will  be  frightened 
at  any  anesthesia,  so  that  the  one  which  produces  unconsciousness 
most  quickly  and  with  safety  is  most  humane.  This  is  undoubt- 
edly nitrous  oxid  gas. 

To  give  the  gas-ether  sequence  successfully  it  is  well  to  make 
sure  of  the  unconsciousness  of  the  patient  before  changing  from 
gas  to  ether.  This  is  the  more  important  if  the  change  must  be 
made  suddenly.  Apparatus  made  especially  for  the  purpose  is 
so  constructed  that  the  anesthetist  can  turn  on  the  ether  while  the 
patient  is  still  breathing  gas.  If  a  change  must  be  made  from  a 
gas  inhaler  to  an  ether  cone  the  patient  should  be  so  well  anes- 
thetized as  to  insure  several  breaths  of  ether  before  the  effect  of 
the  gas  is  wholly  gone.  Even  then  one  will  occasionally  meet  some 
struggling  before  quiet  ether  narcosis  is  established.  After  that 
the  anesthesia  is  like  a  simple  ether  anesthesia. 

Contraindication  to  Ether. — Edema  of  the  glottis,  pres- 
sure on  the  trachea,  and  diseases  of  the  lung,  both  acute  and 
chronic,  and  the  existence  of  a  high  blood  pressure  are  contra- 
indications for  the  use  of  ether.  On  account  of  its  irritating  prop- 
erties many  anesthetists  are  unwilling  to  give  it  to  infants  and 
young  children.  Such  irritation  is  largely  avoided  if  the  warmed 
vapor  is  given.  As  ether  disintegrates  the  blood  to  a  certain  extent, 
it  should  not  be  given  when  the  hemoglobin  is  less  than  fifty  per 
cent,  and  whenever  given  to  an  anemic  person  it  should  be  fol- 
lowed by  oxygen  to  hasten  its  elimination.  Ether  gives  a  post- 
anesthetic depression,  and  is,  therefore,  inferior  to  gas  and  oxygen 
for  grave  surgical  operations  likely  to  be  followed  by  shock. 

Chloroform. — The  anesthetic  properties  of  chloroform  were 
discovered  in  1847  by  James  Simpson.  As  he  was  looking  for  a 
superior  anesthetic  to  ether  at  the  time  of  the  discovery,  he  lost 
no  time  in  proclaiming  the  advantages  of  chloroform. 


CHLOROFORM  755 

Its  odor  is  agreeable.  It  can  be  inhaled  without  irritation. 
The  throat  is  free  from  rnucus  and  there  is  no  cough.  Sleep 
ensues  rapidly — in  five  to  ten  minutes.  Even  alcoholics  and  ath- 
letes readily  succumb  to  its  influence.  Many  persons  recover  from 
it  without  nausea  or  vomiting.  The  quantity  required  for  anes- 
thesia is  small — less  than  an  ounce  an  hour.  It  is,  therefore,  a 
cheap  anesthetic,  and  one  easily  carried  about.  No  special  appa- 
ratus is  required  for  its  administration.  A  folded  handkerchief 
held  near  the  nostrils  answers  very  well,  though  gauze  or  stock- 
inette or  flannel  stretched  over  a  wire  frame  is  to  be  preferred. 

With  these  obvious  advantages,  chloroform  rapidly  became  the 
anesthetic  of  choice  in  most  parts  of  the  world,  and  maintained 
that  supremacy  for  years.  Lately  it  has  been  steadily  losing 
ground  to  ether.  This  has  been  due  solely  to  the  greater  safety 
of  ether,  at  least  in  unskilled  hands.  Whatever  may  be  said  of 
the  safety  of  chloroform  when  given  carefully,  all  must  admit 
that  when  given  carelessly  it  is  a  dangerous  anesthetic.  It  lowers 
the  blood  pressure,  and  hence  should  never  be  administered  sud- 
denly in  a  concentrated  form. 

Methods  of  Administration. — Chloroform  may  be  given  by 
the  open  method  and  by  the  vapor  method. 

Four  thicknesses  of  gauze,  or  a  single  layer  of  stockinette  or 
flannel  is  stretched  on  a  wire  frame  and  held  near  the  mouth  and 
nose.  It  is  not  necessary  to  touch  the  patient  with  the  mask,  but 
even  the  vapor  of  chloroform  is  irritating  to  a  sensitive  skin, 
so  that  nose,  lips,  cheeks,  and  chin  should  be  lightly  smeared  with 
cold  cream  or  vaseline.  The  patient  is  prepared  according  to  the 
rules  given  on  page  716.  The  chloroform  is  dropped  upon  the 
mask  either  from  a  special  bottle  or  from  one  arranged  with 
notches  in  the  cork,  or  with  a  match  or  safety  pin  thrust  between 
the  cork  and  the  neck  of  the  bottle.  The  object  is  to  secure  a 
series  of  rapid  drops  when  the  bottle  is  tilted.  The  bottle  should 
always  be  tested  before  it  is  lifted  over  the  patient's  face. 

While  every  anesthetic  should  be  begun  gradually,  this  is  par- 
ticularly true  of  chloroform,  since  its  freedom  from  irritation 
permits  the  patient  to  inhale  easily  a  fatally  high  percentage  of 
its  vapor.  The  -greatest  caution  should  be  observed  in  passing 
from  gas  or  ether  to  chloroform.     The  stronger  respiration  under 

the  anesthetic  makes  it  doubly  important  that  in  the  first  breaths 
50 


756 


GENERAL    ANESTHESIA 


of  chloroform  the  percentage  of  vapor  should  be  very  low.  One 
should  not  pass  directly  from  ethyl  chlorid  to  chloroform,  but 
should  interpose  a  tew  breaths  of  ether. 

When  forms  of  apparatus  arc  employed  which  indicate  the 

strength  of  the  anesthetic,  it  is  found  that  the  inspired  air  should 


Fig.  416. — Junker's  Apparatus  for  Giving  Chloroform  Vapor  Attached  to  a 
Hollow  Esmarch  Mask.  At  its  side  are  Gwathmey's  combined  tongue  de- 
pressor and  tube  and  an  ordinary  metal  tube  to  deliver  the  vapor  in  the  nose  or 
mouth. 

contain  from  one  and  a  quarter  to  two  per  cent  of  chloroform. 
Three  per  cent  is  dangerous  if  continued  for  many  minutes,  and 
four  per  cent  or  over  may  produce  sudden  death.  For  this  rea- 
son chloroform  should  never  be  given  by  the  closed  method,  and 
when  an  open  mask  is  used  only  a  part  of  the  exposed  surface 
should  be  saturated  with  chloroform — say  one  fourth  of  the 
surface  for  a  dilute  administration,  one  half  on  the  average, 
three  quarters  when  the  patient  requires  an  extra  amount,  but 
this  only  for  a  few  breaths.  The  whole  mask  should  never  be 
saturated. 

Another  method  of  estimating  approximately  the  amount  of 
chloroform  inhaled,  is  to  limit  the  amount  dropped  on  the  gauze 
in  a  period  of  five  minutes.     This  should  not  exceed  6  c.c.  for 


CHLOROFORM 


757 


any  two  consecutive  five-minute  periods.  After  anesthesia  is 
established,  less  than  2  c.c.  in  five  minutes  is  sufficient  to  con- 
tinue it. 

Some  anesthetists  use  a  mask  covered  with  thin  rubber  outside 
of  the  gauze.  In  the  center  of  this  a  hole  is  cut  to  permit  the 
chloroform  to  fall  on  the  gauze.  This  is  an  approach  to  the  closed 
method  of  administration.  It  limits  evaporation  of  chloroform, 
but  gives  the  patient  a  more  concentrated  vapor.  Plenty  of  air 
should  be  allowed  to  enter  under  the  mask.  This  technic  is  not 
recommended  to  a  beginner. 

Chloroform,  when  administered  by  the  vapor  method,  loses 
much  of  its  danger.    This  method,  advocated  by  Junker,  who  de- 


Fig.  417. — Gwathmey's  Three-bottle  Modification  of  Junker's  Apparatus 
for  Giving  Warm  Ether  or  Chloroform  Vapor.  A,  Rubber  foot-pump;  B, 
ball  to  equalize  pressure;  C,  apparatus  with  valve  which  determines  whether  a 
single  vapor  or  a  mixture  shall  be  given;  D,  glass  tube  to  catch  any  liquid  and  pre- 
vent it  reaching  the  patient;  E,  Esmarch  mask  covered  by  thin  rubber  to  retard 
evaporation. 


vised  a  simple  bottle  for  its  employment  (Fig.  416),  has  been  put- 
forward  in  this  country  by  Gwathmey  and  Brophy,  each  of  whom 
has  modified  the  original  Junker  apparatus  so  that  the  chloroform 
vapor  is  warmed  before  the  patient  inhales  it.     This  renders  it 


758 


GENERAL  ANESTHESIA 


[ess  dilute  and  therefore  safer.  The  infrequency  of  accidents 
with  chloroform  in  hot  countries  is  now  generally  admitted  to 
be  due  to  the  fact  that  the  heat  renders  the  inhaled  vapor  less 

drlisc. 

Brophy  uses  a  two-bottle  apparatus;  Gwathmey  a  three-bottle 
one.      In  each  form  of  apparatus  one  bottle  contains  warm  water, 

through  which  the 
chloroform  vapor  is 
driven  by  means  of  a 
foot  pump  or  rubber 
hand  bulb.  In  Gwaih- 
mey's  apparatus  (  Figs. 
417  and  418)  there  is  a 
third  bottle  containing 
ether,  so  that  the  patient 
may  be  given  either 
vapor  or  both  mixed. 

An  English  anes- 
thetist, Alcock,  has  de- 
vised a n  apparatus 
which  will  deliver 
with  accuracy  from 
one  to  three  per  cent 
of  chloroform  vapor 
(Fig.  419).  As  it  is 
made  of  copper,  the 
risk  of  breakage,  so 
common  with  glass  bot- 
tles, is  eliminated.  It 
costs  £6  in  London. 
The  air  is  driven 
through  the  chloroform 
by  a  foot  bellows. 
Dubois  has  also  a  metal  apparatus  in  which  air  is  pumped 
through  chloroform,  the  power  being  supplied  through  a  hand 
crank  or  a  foot  treadle.  The  mixture  of  air  and  chloroform  is 
contained  in  a  gasometer  (Fig.  420).  The  percentage  can  be  regu- 
lated to  one  tenth  of  one  per  cent,  and  the  quantity  supplied  the 
patient  is  abundant.    With  this  apparatus  the  proportion  of  chloro- 


Fig.  418. — Gwathmey's  Apparatus  Turned  Upside 
Down  and  the  Bottles  Removed  to  Show 
— A,  Drum  with  fine  holes  so  that  air  may  escape 
and  pass  upward  through  ether  in  fine  bubbles; 
B,  slender  stem  for  use  in  chloroform;  C,  Sut- 
ton's spiral  so  arranged  that  a  bubble  of  air  has 
to  make  three  complete  revolutions  of  the  drum 
through  liquid  ether  before  escaping  at  the  top  of 
the  drum. 


CHLOROFORM 


759 


form  used  need  not  be  raised  above  two  per  cent,  and  that  only 
for  a  few  minutes.     After  that  1.2  per  cent  is  the  usual  amount 


Fig.  419. — Alcock's  Appakatus  for  Giving  a  Known  Percentage  of  Chloro- 
form Vapor. 


giving 

rather 


given.  There  is  almost  absolute  safety  in  giving  chloroform  in 
this  manner.  The  apparatus  weighs  39  pounds  without  the  foot 
treadle.  That  weighs 
8^  pounds. 

There '  are  only  two 
disadvantages  to  the  va- 
por method  of 
chloroform — the 
complicated  and  some- 
what expensive  appa- 
ratus, and  the  difficulty 
in  getting  under  and 
keeping  under  muscular 
and  alcoholic  patients. 
A  preliminary  hypoder- 
mic of  morphin,  one 
sixth  of  a  grain  to  every 
hundred  pounds  of  the 
patient's  weight,  is  an 
aid.  Alcock  claims  that 
with  his  machine  a 
three-per-cent  vapor  suf- 
fices for  anyone.  It  is 
obvious  that  the  quan- 
tity of  vapor  delivered 


Fig.  420. — Dubois's  Apparatus  for  Giving  Known 
Percentages  of  Chloroform  Vapor.  Power 
may  be  supplied  through  the  handle,  .4,  or  by  the 
foot  piece,  B,  as  modified  by  Chapman. 


760  GENERAL  ANESTHESIA 

must  be  considered  as  well  as  its  percentage,  for  if  the  vapor  is 
not  delivered  into  the  inhaler  fast  enough  to  meet  the  full  de- 
mand of  inspiration,  air  will  leak  in  around  the  face  piece.  An 
adult  inspires  about  ten  liters  a  minute.  Aleock's  apparatus  has 
a  very  large  tube  similar  to  that  of  an  ordinary  dental  inhaler 
for  gas.  -The  tube  of  Gwatlnney's  apparatus  is  much  smaller. 
This  may  account  for  the  difficulty  in  keeping  some  patients 
under  with  it.  When  connected  with  an  Esmarch  inhaler,  with 
a  hollow  rim,  the  inhaler  can  be  covered  with  gauze  and  this 
with  thin  rubber  (part  of  an  old  glove),  in  the  center  of  which 
a  small  hole  is  cut  to  receive  drops  of  liquid  chloroform.  It  is 
only  necessary  to  use  the  dropper  in  the  beginning  of  the  anes- 
thesia or  if  the  patient  partially  comes  out. 

No  definite  rules  can  be  given  for  the  relative  amounts  of  ether 
and  chloroform  vapor  to  be  used.  An  increase  in  the  proportion 
of  chloroform  vapor  deepens  the  anesthesia,  while  an  increase  in 
the  proportion  of  ether  stimulates  respiration  and  possibly  light- 
ens the  anesthesia.  One  soon  learns  the  technic  of  vapor  anes- 
thesia, and  also  to  recognize  when  a  patient  will  do  better  under 
more  or  less  of  ether  or  chloroform. 

Dangers  and  Accidents  with  Chloroform. — While  the 
symptoms  of  danger  during  anesthesia  and  the  treatment  therefor 
are  given  in  the  first  part  of  this  chapter,  it  is  worth  empha- 
sizing that  the  first  sign  of  danger  under  chloroform  is  often  an 
increased  respiration  with  pallor  and  dilated  pupils.  If  this  first 
warning  signal  is  neglected  and  the  mask  is  kept  in  place,  the 
danger  is  doubled,  since  the  exaggerated  breathing  instead  of  free- 
ing the  body  from  a  poison,  actually  increases  the  amount  inhaled 
and  therefore  absorbed.  Tests  have  shown  that  it  takes  about  one 
minute  for  the  full  effects  of  the  inhaled  chloroform  to  manifest 
themselves,  so  that  one  cannot  be  too  careful  to  observe  the  early 
symptoms  of  danger,  of  which  this  irregularity  in  breathing  seems 
to  be  the  first.  Free  air,  and  if  necessary  vigorous  artificial  res- 
piration, are  the  safeguards.  Other  details  of  the  treatment  of 
shock  during  chloroform  anesthesia  have  been  given  on  page  728 
et  seq.  jSTote  also  what  has  been  said  under  "  status  lymphaticus," 
on  page  73").  Brief  inversion  of  a  patient  is  useful  to  empty  the 
heavy  vapor  out  of  the  lungs.  Alternately  inverting  a  patient  and 
then  holding  him  upright  is  a  powerful  means  of  resuscitation, 


ETHYL  CHLORID  761 

and  is  said  to  have  restored  cardiac  activity  when  other  means 
have  failed. 

When  normal  respiration  has  been  restored  the  anesthetist  must 
decide  whether  to  continue  with  chloroform  or  to  change  to  ether. 
If  the  chloroform  was  given  carefully  and  shock  resulted,  a  change 
to  ether  is  usually  advisable. 

Ethyl  Chlorid. — Ethyl  chlorid,  known  chemically  for  nearly 
four  hundred  years,  was  first  used  as  a  general  anesthetic  in  1848. 
Its  dangerous  qualities  were  soon  recognized,  and  it  was  abandoned 
for  a  half  century.  In  the  past  ten  years  it  has  been  extensively 
used,  chiefly  to  induce  anesthesia.  It  is  a  clear  liquid,  boiling  at 
55°  F.,  and  on  account  of  its  extreme  volatility  it  is  conveniently 
sold  in  glass  tubes  in  one  end  of  which  is  a  capillary  opening  fitted 
with  a  valve. 

When  ethyl  chlorid  is  freely  inhaled  unconsciousness  is  pro- 
duced with  great  rapidity — perhaps  after  three  or  four  breaths. 
When  taken  more  slowly  the  reflexes  can  be  observed  to  disappear, 
the  respiration  deepens  and  there  may  be  a  slight  snoring ;  the  face 
is  a  little  flushed,  and  the  pupils  are  dilated  but  react  to  light ;  but 
muscular  relaxation  may  be  a  little  delayed.  It  will  thus  be  seen 
that  the  symptoms  resemble  those  of  ether  anesthesia,  except  that 
the  changes  occur  much  faster  and  symptoms  of  irritation  to  the 
air  passages  are  lacking.  For  the  sake  of  safety  the  drug  should 
be  given  slowly  so  that  one  or  two  minutes  elapse  before  uncon- 
sciousness is  complete.  The  amount  required  for  the  purpose  is 
from  5  to  10  ccm.  when  a  partially  open  cone  is  employed. 

Apparatus.- — Ethyl  chlorid  can  be  sprayed  upon  an  ordinary 
Esmarch  mask  covered  with  gauze,  or  it  may  be  sprayed  upon  a 
gauze  diaphragm  placed  within  or  inserted  in  the  side  of  almost 
any  form  of  inhaler.  Many  of  them  have  provision  for  this  pur- 
pose. Some  anesthetists  break  a  glass  pearl  containing  ethyl  chlo- 
rid within  the  bag  of  a  closed  inhaler.  This  is  not  advisable,  as 
it  gives  the  patient  a  concentrated  vapor  at  the  start.  It  is  better 
to  begin  with  a  dilute  vapor  and  gradually  increase,  even  though 
some  ethyl  chlorid  is  wasted.  The  expense  is  inconsiderable — 
only  one  half  that  of  gas. 

When  an  overdose  is  given  the  respirations  grow  feeble,  and 
after  a  few  breaths  cease  altogether.  The  pulse  continues  beyond 
respiration.     If  the  apparatus  is  removed  and  artificial  respira- 


762  GENERAL  ANESTHESIA 

tion  at  once  performed  recovery  promptly  follows  in  most  cases. 
The  effect  of  the  ethyl  chloral  passes  off  very  rapidly,  so  that  the 
danger  is  slight  if  the  anesthetist  is  on  the  watch  for  failing  respi- 
ration and  is  quick  to  act.  But  delay  of  half  a  minute  may  be 
fatal.  After-effects  are  slight.  About  one  half  of  the  patients 
experience  nausea  and  vomiting,  hut  the  symptoms  are  of  short 
duration.  Cases  of  fatly  degeneration  of  the  solid  viscera  occur- 
ring after  ethyl  chlorid  have  been  reported.  For  symptoms  and 
treat  nteiit  see  "  Acid  Intoxication,"'  page  7-'!<>. 

Contraindications  for  the  use  of  ethyl  chlorid  to  induce  anes- 
thesia are  any  form  of  obstruction  of  the  respiratory  passages,  and 
weak  or  irregular  cardiac  action.  Several  accidents  have  been 
reported  from  its  administration  for  tonsilectomy  and  other  opera- 
tions in  the  throat.  Its  use  should  be  restricted  to  induction  anes- 
thesia and  as  the  sole  anesthetic  for  minor  operations.  If  it  is  to 
be  followed  by  chloroform  the  change  should  not  be  made  directly, 
but  a  few  breaths  of  ether  should  intervene,  lest  the  heart  suffer 
from  the  combined  depressing  effects  of  the  two  drugs.  Mortality 
from  its  use  is  variously  stated  from  one  death  in  200  cases  up 
to  one  death  in  8,000  cases. 

Somnoform. — Somnoform  is  a  combination  of  ethyl  chlorid 
(sixty  per  cent),  methyl  chlorid  (thirty-five  per  cent),  and  ethyl 
bromid  (five  per  cent).  It  acts  quickly,  and  the  ethyl  bromid  has 
a  sedative  and  analgesic  action  which  is  intended  to  prolong  and 
deepen  narcosis.  It  is  said  to  be  pleasanter  to  take  than  ethyl 
chlorid ;  otherwise  the  indications  for  its  use,  the  symptoms  it  pro- 
duces, and  the  effects  of  an  overdose  are  exactly  as  detailed  above 
under  ethyl  chlorid.  Several  deaths  from  somnoform  have  been 
reported. 

Mixed  Anesthetics.  —  The  anesthetic  sequences  in  common 
use  have  been  spoken  of  under  the  different  headings  of  this  chap- 
ter. A  few  words  should  be  said  concerning  mixed  anesthetics. 
The  best  known  is  the  A.  C.  E.  mixture :  alcohol,  one  volume ; 
chloroform,  two  volumes ;  and  ether,  three  volumes.  More  re- 
cently in  England  the  C.  E.  mixture  is  advocated,  consisting  of 
chloroform  (two  volumes)  and  ether  (three  volumes).  It  has  been 
asserted  by  various  advocates  of  mixtures  that  the  different  in- 
gredients volatilize  equally  so  that  their  proportion  always  remains 
the  same.     Careful  analyses  have,  however,  proved  what  common 


HYPODERMIC   ANESTHESIA  763 

sense  suspected,  that  the  lighter  drug  volatilizes  more  rapidly,  so 
that  as  anesthesia  progresses  the  percentage  of  the  heavier  one 
(chloroform  in  the  examples  mentioned)  is  constantly  increasing 
in  the  inspirations.  For  this  reason,  mixtures  of  dissimilar  sub- 
stances have  failed  to  gain  any  secure  foothold  in  this  country, 
and  are  still  less  likely  to  do  so  in  the  future.  If  an  anesthetist 
wishes  to  give  his  patient  a  mixture  of  anesthetics  he  should  give 
them  in  such  a  manner  that  he  is  able  to  regulate  the  quantity  of 
each  that  he  is  administering. 

Hypodermic  Anesthesia. — The  discovery  of  hypodermic 
medication  is  credited  to  Wood,  of  Edinburgh,  in  1843.  In  1858 
Charles  Hunter  pointed  out  the  effect  upon  the  brain  caused  by 
drugs  introduced  subcutaneously,  but  the  idea  of  so  using  them 
to  produce  general  anesthesia  for  surgical  operations  was  much 
longer  delayed.  In  1885  Corning  introduced  spinal  anesthesia 
(often  called  analgesia),  and  the  possibilities  of  this  method  and 
of  Schleich's  methods  of  infiltration  anesthesia  occupied  the  atten- 
tion of  investigators  for  fifteen  years. 

In  1900  Schneiderlin  made  his  first  tests  with  scopolamin- 
morphin  anesthesia,  using  gr.  two  an&  gr-  e  °f  the  two  drugs.  He 
employed  it  as  a  preliminary  to  ether  or  chloroform.  Within  a 
few  years  he  reported  nearly  three  thousand  successful  cases. 
Since  1905  the  method  has  been  extensively  followed  in  this  coun- 
try both  as  a  preliminary  to  another  anesthetic  and  as  the  sole 
anesthetic.  Various  combinations  of  drugs  have  been  employed 
and  long  discussions  have  been  held  as  to  their  respective  merits, 
and  especially  in  regard  to  the  substitution  of  hyoscin  for  scopo- 
lamin.  Without  going  further  into  this  controversy,  it  may  be 
safely  stated  that  the  use  of  hyoscin  in  preference  to  scopolamin 
has  distinctly  increased,  so  that  the  combination  may  be  regarded 
as  satisfactory.  A  tablet  containing  hyoscin  (gr.  yro )?  morphin 
(gr.  |),  and  cactin  (gr.   -^T)  is  extensively  employed. 

When  used  as  a  preliminary  to  inhalation  anesthesia  one  hypo- 
dermic tablet  given  one  half  hour  previous  is  sufficient  to  calm 
the  patient  and  reduce  sensibility  to  such  an  extent  that  much  less 
of  the  volatile  anesthetic  is  required.  If  no  other  anesthetic  is  to 
be  employed  the  injection  must  be  repeated  once,  or  often  twice, 
and  even  then  the  operator  must  be  prepared  to  tie  or  hold  the 
patient  and  to  turn  a  deaf  ear  to  expostulation  or  abuse.     It  is 


764  GENERAL   ANESTHESIA 

claimed,  and  justly  in  many  cases,  that  the  patient  so  treated  re- 
members nothing  of  the  operation;  but  given  in  these  large  doses 
the  drugs  are  distinctly  dangerous,  and  deaths  have  followed 
their  use. 

Cardiac  or  respiratory  depression  are  to  be  combated  by  rec- 
tal injection  of  hot  colfee,  external  heat,  artificial  respiration, 
forced  muscular  action,  and  gastric  lavage,  since  the  stomach 
always  excretes  a  considerable  part  of  drugs  injected  hypodermic- 
ally.  Permanganate  of  potash  in  a  one-per-cent  solution  may  be 
passed  through  the  stomach  tube,  or  given  to  the  patient  to  drink. 
Pilocarpin  and  spirits  of  nitrous  ether  may  be  given  to  hasten 
elimination  through  the  kidneys,  and  the  urine  should  be  passed 
frequently  or  drawn  by  catheter  to  prevent  reabsorption  from  the 
bladder.  Recovery  is  to  be  expected  even  when  the  respiratory 
rate  is  very  low  and  delirium  is  pronounced.  The  method  has 
been  much  used  in  obstetrics — a  single  tablet  of  the  strength  men- 
tioned above  being  given  in  two  doses.  A  little  chloroform  will 
be  needed  to  secure  muscular  relaxation.  If  more  than  one  such 
tablet  is  injected  the  effect  upon  the  child  is  rather  noticeable. 

Hypodermic  anesthesia  of  this  general  character  is  absolutely 
unsuited  for  operations  which  only  last  a  few  minutes,  for  it  takes 
hours  for  the  effect  of  the  injection  to  pass  away.  This  fact  is 
one  of  the  points  in  its  favor  in  operations  likely  to  be  followed 
by  prolonged  discomfort.  Of  its  value  in  permitting  the  surgeon 
to  dispense  with  the  services  of  an  anesthetist  in  cases  of  emer- 
gency there  can  be  no  doubt  whatever,  but  there  seems  no  reason 
to  suppose  that  hypodermic  anesthesia  will  supplant  inhalation 
anesthesia  until  some  more  powerful,  and  at  the  same  time,  less 
dangerous  drugs  are  discovered  than  those  employed  up  to  the 
present  time. 

Rectal  Anesthesia. — Rectal  anesthesia  is  of  advantage  in 
two  classes  of  cases.  First,  those  in  which  inhalation  is  difficult, 
for  example,  in  operations  on  the  head  and  neck ;  second,  those  in 
which  it  is  desired  to  avoid  the  bronchial  irritation  of  ether.  It 
is  true  that  ether  is  largely  excreted  by  the  lungs,  but  it  is  then 
warmed  and  well  diluted.  Rectal  anesthesia,  using  ether,  was 
tried  by  Pirigoff  in  1847,  and  has  been  taken  up  spasmodically 
many  times  since  then.  The  early  experimenters  warmed  the  ether 
until  it  boiled  and  allowed  the  vapor  to  escape  into  the  rectum. 


RECTAL  ANESTHESIA  765 

In  1905  Cunningham  adopted  the  vapor  method,  forcing  air 
through  ether  and  into  the  rectum. 

The  principles  of  successful  anesthesia  are  an  empty  bowel, 
ether  well  vaporized,  moderate  distention  of  the  rectum  by  the  air 
and  ether,  and  the  escape  of  the  air  from  the  rectum  from  time  to 
time.  A  simple  apparatus  consists  of  a  rubber  hand  bulb  such  as 
is  used  with  a  thermocautery,  attached  to  a  Wolff  bottle  holding 
eight  ounces,  the  outlet  tube  having  a  "  U  "  in  it  or  some  other 
device  for  catching  condensed  ether.  Somewhere  between  the  soft- 
rubber  tube,  which  is  passed  into  the  rectum,  and  the  AVolff  bottle 
there  is  a  glass  "  T  "  or  "  Y."  To  one  of  its  openings  a  short 
piece  of  rubber  tubing  is  fitted  and  clamped.  From  time  to  time 
the  clamp  is  released  to  permit  accumulated  air  and  ether  to 
escape  from  the  rectum.  It  requires  from  fifteen  to  twenty  min- 
utes, to  anesthetize  a  patient.  Undue  distention  of  the  bowel  must 
be  avoided.  When  the  outlet  tube  is  opened  every  three  to  five 
minutes  air  must  escape ;  otherwise  it  is  an  indication  that  the 
rectal  tube  is  not  free.  The  water  in  the  wash  bottle  should  be 
kept  just  below  blood  temperature  (37°  C).  ISTo  ether  should  be 
allowed  to  run  back  in  the  bulb.  If  the  room  is  cold  ether  is  liable 
to  condense  in  the  tube.  All  air  and  ether  should  be  allowed  to 
escape  from  the  rectum  before  the  tube  is  withdrawn. 

Rectal  anesthesia  is  not  without  danger,  deaths  from  it  having 
already  been  reported.  It  has  been  abandoned  by  some  of  those 
who  have  once  favored  it,  vapor  anesthesia  through  the  nostrils 
having  taken  its  place  in  operations  upon  the  mouth  and  throat. 

When  it  is  employed  the  patient  should  first  be  anesthetized  to 
unconsciousness  in  the  usual  manner  before  the  rectal  anesthesia 
is  begun,  for  the  latter  is  quite  disagreeable. 

Oil-ether  Method. — A  method  of  rectal  anesthesia  quite 
different  from  the  above  was  proposed  by  Gwathmey  and  first 
employed  by  him  in  1913.  It  consists  in  mixing  ether  and  a 
non-irritating  oil  and  injecting  the  mixture  into  an  empty  rectum. 
Anesthesia  is  produced  in  from  fifteen  minutes  to  an  hour  and 
lasts,  according  to  condition  of  its  employment,  from  one  to  four 
or  more  hours.  The  details  of  this  method  of  anesthesia  are  not 
as  yet  fully  decided  upon.  For  those  who  would  employ  it  the 
following  directions  are  given: 

Ether  and  liquid  petrolatum    (paraffin  oil)    are   mixed  in  a 


766  GENERAL   ANESTHESIA 

bottle  in  the  proportion  of  two  measured  ounces  of  the  former  I" 
one  of  the  latter.  It  is  well  to  remember  that  four  ounces  of 
ether  by  weight  measure  nearly  six  fluid  ounces.  In  estimating 
the  dose  required,  it  is  safe  to  inject  one  measured  ounce  of  ether 
for  each  thirty  pounds  of  the  patient's  weight  If  he  is  alcoholic 
or  robust  a  little  more  may  be  given.  If  he  is  anemic  or  weakened 
by  disease  even  a  less  quantity  will  suffice. 

The  bowel  should  be  empty,  but  not  irritated  by  repeated 
enemas.  A  hypodermic  injection  of  morphin,  -J  grain  to  each  one 
hundred  pounds  of  body  weight,  should  precede  the  rectal  injec- 
tion of  oil  and  ether.  A  rectal  tube  or  soft  rubber  catheter  is 
passed  a  couple  of  inches  into  the  rectum,  a  glass  funnel  attached, 
and  the  oil-ether  mixture  administered.  It  feels  a  little  hot  to 
the  patient,  but  not  painful,  and  the  sensation  lasts  only  a  few 
minutes.  Sometimes  there  is  a  little  involuntary  straining  and 
the  mixture  may  be  forced  back  into  the  funnel.  On  this  account 
it  is  well  to  have  two  feet  or  more  of  rubber  tubing,  so  that  the 
pressure  can  be  increased  by  raising  the  funnel.  The  fluid  should 
be  passed  in  slowly,  and  the  flow  checked  from  time  to  time.  Five 
or  ten  minutes  should  be  used  for  the  injection;  the  patient  cau- 
tioned against  straining,  and  the  tube  withdrawn.  In  five  minutes 
ether  is  noticeable  on  the  patient's  breath  and  he  begins  to  feel 
sleepy.  A  towel  laid  over  the  face  compels  a  partial  rebreathing 
and  hastens  the   anesthesia. 

In  half  an  hour,  more  or  less,  the  patient  is  ready  for  opera- 
tion. The  condition  is  more  like  a  natural  sleep  than  it  is  like 
a  mouth  anesthesia.  Color  is  normal,  breathing  is  not  accelerated, 
pulse  usually  not  above  80.  There  is  no  increased  flow  of  saliva — 
no  rattling  of  mucus  in  the  throat.  With  the  light  dose  advocated 
above  the  reflexes  may  not  be  entirely  lost,  and  with  some  patients 
it  is  necessary  to  give  ten  or  twenty  drops  of  ether  on  a  mask 
from  time  to  time,  to  get  perfect  muscular  relaxation.  Other 
patients  are  absolutely  relaxed  and  remain  quiet,  while  the  re- 
flexes are  sufficiently  preserved  to  permit  them  to  answer  ques- 
tions. Others  are  more  deeply  anesthetized.  The  quieting  effect 
of  a  little  ether  on  the  mask  seems  all  out  of  proportion  to  the 
amount  used — doubtless  because  of  the  ether  already  in  the  blood. 

As  soon  as  the  operation  is  completed,  or  sooner  if  circum- 
stances indicate  this,  the  oil-ether  mixture  should  be  washed  from 


SPINAL  ANALGESIA  767 

the  rectum,  two  soft  rubber  tubes  being  provided  for  the  purpose, 
one  for  the  inflow  of  cool  water  and  the  other  for  the  outflow. 

Rectal  anesthesia  by  the  oil-ether  method  is  a  most  valuable 
discovery.  The  absence  of  respiratory  irritation  and  the  evenness 
of  the  anesthesia  are  its  most  striking  characteristics.  The  pa- 
tient goes  slowly  under  it,  remains  at  about  the  same  level  for  a 
long  time,  and  regains  consciousness  slowly.  The  patients  have 
less  nausea  and  vomiting  than  do  most  of  those  anesthetized  by 
other  methods. 

Thus  far  it  has  been  shown  to  have  only  two  drawbacks.  A 
young  child  or  a  partially  anesthetized  person  may  expel  the 
mixture  before  anesthesia  is  complete,  thus  requiring  mouth  anes- 
thesia or  a  second  injection.  A  more  serious  disadvantage  lies 
in  the  difficulty  of  stopping  the  anesthetic  if  the  patient  is  too 
deeply  anesthetized.  Washing  out  the  rectum  is  only  a  partial 
relief.  Sometimes  very  little  of  the  mixture  is  obtained,  prob- 
ably because  it  has  passed  too  far  upward.  A  deep  unconscious- 
ness lasting  for  hours,  cessation  of  respiration  requiring  artificial 
aid  for  several  minutes,  and  even  death  have  followed  an  overdose 
of  ether  administered  by  this  method.  It  seems,  therefore,  wise 
to  keep  the  dose  so  light  that  a  little  mouth  administration  is 
necessary,  at  least  at  the  beginning  of  operation.  In  every  case 
the  patient  should  be  kept  under  observation  until  the  reflexes  are 
thoroughly  established. 

If  carefully  given,  oil-ether  rectal  anesthesia  saves  the  patient 
from  fear  of  the  anesthetic,  from  the  feeling  of  suffocation,  from 
respiratory  irritation,  from  shock  due  to  struggling,  from  vomit- 
ing during  operation,  and  from  strain  on  the  heart  or  other  organs, 
due  to  sudden  changes  in  the  amount  of  anesthetic  administered. 

Spinal  Analgesia. — This  method  of  preparing  a  patient  for 
operation  competes  with  general  anesthesia ;  at  least,  in  operations 
below  the  thorax,  and  therefore  merits  consideration  here.  The 
technic  of  lumbar  puncture  is  described  on  page  581.  The  sitting 
or  "  scorcher's  "  posture  is  preferred  to  lateral  decubitus  by  most 
operators.  In  stout  persons,  whose  lumbar  spines  are  felt  with 
difficulty,  it  is  well  to  remember  that  the  third  space  is  slightly 
above  the  iliac  crests.  The  second  space  is  better  for  injection 
than  the  third.  Cocain  for  spinal  injection  has  largely  given  place 
to  stovain,  tropococain   or  novococain.     These  drugs  have  an  anal- 


768  GENERAL  ANESTHESIA 

gesic  power  less  than  cocain,  bu1  si  ill  sufficiently  greal  in  most 
cases,  and  poisonous  symptoms  following  their  use  are  less  fre- 
quent and  less  severe. 

The  needle  is  inserted  with  the  wire  in  place  to  a  depth  of 
about  two  inches.  When  the  wire  is  withdrawn  clear  fluid  should 
escape  in  rapid  drops.  If  it  fails  to  do  so  a  cough  may  bring  it 
out.  If  this  fails  a  further  puncture  may  be  necessary.  If  cloudy 
fluid  is  obtained  the  injection  should  be  abandoned,  as  serious 
results  have  followed  its  use  in  meningitis.  When  fifteen  or 
twenty  drops  have  escaped  the  syringe  is  attached  to  the  needle, 
and  the  solution  of  the  drug  chosen  is  slowly  injected  into  the 
spinal  canal.  The  needle  is  withdrawn  and  the  opening  sealed 
with  collodion.  Another  method  is  to  allow  spinal  fluid  to  escape 
into  a  glass  containing  the  drug  in  dry  form.  As  soon  as  it  is  dis- 
solved in  the  spinal  fluid  the  whole  is  reinjected. 

The  dose  of  cocain  injected  should  not  exceed  one  half  grain, 
that  of  stovain  or  tropococain  should  not  exceed  one  grain,  and  that 
of  novococain  three  quarters  of  a  grain.  These  amounts  are  for 
a  person  weighing  150  pounds.  The  addition  of  a  small  amount 
of  adrenalin  has  been  tried  and  generally  abandoned,  as  it  in- 
creases headache  and  other  bad  symptoms.  Whatever  drug  is 
employed  for  injection,  the  solution  should  be  freshly  made  and 
sterile.  Stovain  is  said  to  stand  boiling  without  loss  of  analgesic 
power. 

Unless  the  field  of  operation  is  above  the  diaphragm  the  patient 
should  remain  sitting  until  sensation  begins  to  be  dulled.  Then 
he  should  carefully  resume  the  dorsal  position  with  head  and 
shoulders  slightly  raised.  A  reversed  position  sends  the  injected 
fluid  toward  the  brain  and  raises  the  upper  margin  of  analgesia, 
but  it  also  increases  the  chance  of  post-operative  headache  and 
nausea.  These  changes  may  or  may  not  be  due  to  gravity,  the 
injected  fluid  having  a  higher  specific  gravity  than  that  of  the 
spinal  fluid,  which  is  about  1.007. 

Heat  sense  is  first  lost,  then  the  sense  of  pain,  while  tactile 
sensation  is  usually  not  completely  lost,  and  occasionally  motor 
paralysis  is  observed.  The  patient  is  ready  for  operation  in  eight 
or  ten  minutes  in  most  cases. 

A  preliminary  hypodermic  injection  of  morphin  (gr.  >§)  with 
atropin    (gr.  j\^)    or  scopolamin    (gr.  yot)    ^s   advisable  with 


CHOICE   OF   ANESTHETIC  769 

nervous  patients,  and  before  operations  upon  the  very  sensitive 
tissues  of  the  lower  pelvis. 

One  half  or  two  thirds  of  the  patients  subjected  to  spinal 
injection  suffer  no  serious  discomfort,  the  operation  proceeds 
smoothly,  heart  and  lungs  act  normally,  there  is  no  shock  and  no 
post-operative  pneumonia  attributable  to  the  puncture,  other  than 
a  transient  nausea  or  a  little  headache.  And  even  these  slight 
symptoms  may  usually  be  avoided  by  a  cup  of  tea  before  injection 
or  a  drink  of  coffee  or  wine  at  the  close  of  operation,  and  absolute 
quiet  for  a  couple  of  hours. 

About  one  quarter  to  one  third  of  the  patients  (statistics  differ 
so  it  is  impossible  to  speak  exactly)  suffer  from  more  marked 
symptoms  of  shock  with  altered  respiration  and  pulse,  or  f  aintness, 
or  repeated  vomiting,  or  severe  headache  for  hours,  or  possibly  for 
days.  Inability  to  pass  urine  and  feces  is  also  a  fairly  common 
complication.  A  still  smaller  number  of  patients,  estimated  about 
one  in  eight  hundred,  succumb  immediately  or  in  a  day  or  so  under 
conditions  which  make  the  death  fairly  attributable  to  the  injec- 
tion. There  are  also  a  few  patients,  probably  less  than  ten  per 
cent,  in  whom  no  satisfactory  analgesia  develops,  although  all  the 
conditions  of  injection  are  satisfactory.  Some  operators  advise  a 
second  injection  in  such  cases,  but  it  is  probably  safer  to  supple- 
ment the  injection  with  an  inhaled  anesthetic,  especially  as  the 
amount  of  the  latter  required  will  be  small. 

The  use  of  spinal  analgesia  is  especially  indicated  when 
patients  have  symptoms  making  inhalation  anesthesia  dangerous, 
such  as  feeble  cardiac  or  pulmonary  action,  interference  with  free 
respiration  due  to  goiter  or  other  cervical  tumors  or  swellings, 
status  lymphaticus,  advanced  hepatic  or  renal  disease,  etc.  Many 
of  these  patients  are  bad  operative  risks,  and  there  will  naturally 
be  a  higher  post-operative  mortality  than  when  similar  operations 
are  performed  on  healthier  persons,  irrespective  of  the  anesthetic 
employed. 

Another  indication  for  spinal  analgesia,  as  for  hypodermic 
anesthesia,  is  in  emergencies  when  a  suitable  anesthetic  is  not  at 
hand. 

Choice  of  Anesthetic. — Much  that  has  been  written  upon 
the  choice  of  an  anesthetic  is  absolutely  worthless.  For  example, 
taking  three  recent  books  on  anesthetics :  One  author  advises  pure 


770  GENERAL   ANESTHESIA 

chloroform  in  infants,  a  second  pure  other,  and  the  third  says  it  is 
not  rational  to  choose  an  anesthetic  according  to  the  age  of  the 
patient,  and  then  on  another  page,  forgetting  his  own  statement, 
says,  "  as  a  general  rule,  ether  should  not  be  given  to  patients 
over  sixty  years  of  age." 

There  are,  however,  a  few  facts  in  regard  to  the  choice  of  an 
anesthetic  which  are  indisputable.  The  good  and  bad  points  of 
each  anesthetic,  snch  as  their  cost,  difficulty  of  administration, 
tendency  to  irritate,  etc.,  have  been  already  given  under  the  dif- 
ferent headings.  At  the  risk  of  a  certain  amount  of  repetition 
it  is  well  to  consider  here  the  choice  of  an  anesthetic  in  different 
diseased  conditions,  never  forgetting,  however,  that  the  choice  of 
an  anesthetist  is  far  more  important  than  the  choice  of  an  an- 
esthetic. 

Patients  with  a  beard  are  not  easily  anesthetized  by  any 
method  requiring  an  exact  application  of  the  mask — e.  g.,  nitrous 
oxid,  either  alone  or  with  oxygen.  The  difficulty  can  be  lessened 
by  smearing  the  face  heavily  with  vaseline,  and  by  allowing  the 
gas  to  stream  so  freely  into  the  face  piece  that  it  escapes  under  its 
edge  at  all  times. 

Patients  having  partially  obstructed  air  passages  are  bad  sub- 
jects for  an  anesthetic  (ether),  which  irritates  the  mucous  mem- 
brane and  excites  the  secretion  of  mucus,  or  one  (gas)  which 
causes  cyanosis  and  thus  a  swelling  of  the  mucous  membrane,  or 
one  (ethyl  chlorid)  which  is  dangerous  unless  there  is  plenty  of 
air  mixed  with  it.  Examples  of  patients  in  this  class  are  those 
having  nasal  obstruction,  patients  with  laryngeal  or  tracheal  ob- 
struction due  to  condition  within  or  pressure  from  outside  of  the 
air  passages,  and  inflammations  of  the  air  passages — laryngitis, 
bronchitis,  pneumonia,  tuberculosis,  etc.  Irritation  due  to  ether 
can  be  reduced  to  a  minimum  by  diluting  and  warming  the  vapor, 
and  the  cyanosis  of  nitrous  oxid  can  be  avoided  by  giving  it  with 
oxygen,  so  that  the  contraindications  are  relative  and  not  absolute. 

Nasal  stenosis  means  that  the  patient  must  breathe  through 
his  mouth,  so  that  a  gag  should  be  inserted  before  the  anesthesia 
unless  the  patient  objects.  In  that  case  it  can  be  deferred  until 
unconsciousness  is  reached.  Adenoids  and  tonsils  are  rarely  of 
sufficient  size  to  obstruct  respiration  on  account  of  the  width  of  the 
nose  and  pharynx.     It  is,  of  course,  true  that  patients  with  tuber- 


CHOICE   OF   ANESTHETIC  771 

culosis  of  the  lungs  often  take  ether  withoul  ill  effect.  Some 
enthusiastic  advocates  of  ether  even  speak  of  its  curative  effects 
upon  pulmonary  tuberculosis,  but  there  can  be  no  doubt  that  de- 
structive processes  have  been  started  by  careless  etherization  of 
such  patients.  Whether  the  ether  per  se  is  at  fault,  or  whether 
the  injury  is  due  to  the  excess  of  mucus,  the  chilling  of  the  patient 
due  to  breathing  a  freezing  vapor  for  a  long  time,  or  inhalation  of 
vomited  material,  is  beside  the  mark,  unless  the  ether  is  given  in 
a  manner  to  avoid  these  things. 

Patients  with  a  high  blood  pressure,  especially  if  there  is  a 
history  of  apoplexy,  should  not  be  given  an  anesthetic  which  nota- 
bly raises  blood  pressure  (ether  by  the  closed  method),  nor  should 
the  anesthetic  be  of  a  character  to  produce  coughing,  straining, 
and  vomiting.  But  these  things  are  due  more  to  the  lack  of  skill 
in  the  anesthetist  than  to  the  chemical  agent  chosen.  However, 
chloroform  or  chloroform  mixtures  prove  very  serviceable  in  cases 
of  high  blood  pressure. 

Anemic  patients  and  other  patients  with  low  blood  pressure 
from  shock  or  other  causes  should  not  be  given  an  anesthetic 
(chloroform)  which  will  still  further  lower  blood  pressure.  This 
applies  also  to  ethyl  chlorid.  A  minimum  of  anesthetic  should  be 
given  in  these  cases.  Ether  answers  well,  but  nitrous  oxid  and 
oxygen  are  better.  They  render  a  great  service  to  patients  whose 
surgical  complications  tend  to  produce  shock.  Ether  tends  to  dis- 
integrate hemoglobin,  and  should  not  be  used  if  hemoglobin  is 
less  than  fifty  per  cent  of  normal. 

It  should  be  recognized  that  patients  with  heart  disease  are 
to  be  judged  by  the  action  of  the  heart  muscle  rather  than  by  any 
murmurs  which  may  be  present.  They  should,  therefore,  be  di- 
vided for  anesthetic  purposes  into  those  with  high  tension,  those 
with  low  tension,  and  a  third  large  group  of  those  who  are  essen- 
tially normal  as  far  as  anesthesia  is  concerned.  It  is  well  known 
that  excitable,  rapid  hearts  often  become  strong  and  regular  under 
an  anesthetic. 

With  patients  having  diseases  of  the  liver  or  kidney  preference 
should  be  given  to  nitrous  oxid  and  oxygen,  as  ether  and  chloro- 
form both  injure  these  organs,  though  in  most  cases  temporarily. 
The  occurrence  of  acid  intoxication  and  fatty  degeneration  is  more 
frequent  after  chloroform  than  after  ether.     These  patients  should 


772  GENERAL   ANESTHESIA 

have  before  and  after  the  anesthesia  treatment  to  counteract  the 
development  of  acid  intoxication  (see  page  736).  Spinal  or  hypo- 
dermic anesthesia  should  be  considered  with  these  patients. 

The  status  lymphaticus  is  a  contraindication  for  the  use  of 
chloroform  or  ethyl  chlorid,  on  account  of  the  Low  blood  pressure. 
If  gas  is  used  it  should  be  properly  diluted  with  oxygen  to  avoid 
swelling  of  the  neck  due  to  cyanosis. 

Although  many  diabetics  take  an  anesthetic  well  and  suffer 
no  after  effects,  others  pass  into  coma  and  die  with  symptoms 
similar  to  those  of  acid  intoxication.  This  is  more  likely  to 
happen  in  advanced  or  untreated  cases.  Hence  a  diabetic  pa- 
tient should  he  given  treatment  for  some  days  previous  to  anes- 
thesia in  order  to  reduce  his  symptoms  and  improve  his  general 
condition. 

Anesthesia  is  difficult  in  operations  upon  the  nose,  mouth,  and 
throat.  If  the  operation  is  a  short  one  the  patient  can  be  anes- 
thetized in  the  usual  manner,  the  apparatus  removed,  and  the 
operation  performed.  This  is  the  plan  followed  by  dentists  in 
extracting  teeth.  It  suffices  for  operations  lasting  only  half  a 
minute  or  so.  Longer  operations  can  be  performed  by  alternating 
the  anesthetic  and  the  operating.  This  method,  crude  as  it  is,  is 
doubtless  still  employed  in  a  large  majority  of  such  cases.  It 
doubles  the  time  of  operation,  entails  needless  hemorrhage,  compels 
the  patient  to  swallow  quantities  of  blood,  etc.  To  obviate  these 
disadvantages  various  changes  in  technic  have  been  tried.  Rectal 
anesthesia  is  one  of  the  most  radical.  For  reasons  given  elsewhere 
it  is  not  satisfactory.  Vapor  anesthesia  can  be  used  in  these  head 
cases  in  a  nnmber  of  ways.  The  vapor  can  be  conducted  into  the 
month  along  one  of  the  handles  of  a  mouth  gag  (Fig.  421).  This 
acts  well  in  the  removal  of  tonsils  and  other  operations  at  the  back 
of  the  mouth  or  in  the  throat. 

Another  plan  is  to  deliver  the  vapor  of  ether  or  chloroform 
through  one,  or,  better,  both  nostrils.  There  are  special  tubes 
manufactured  for  this,  but  any  soft-rubber  tubes  will  answer,  pro- 
vided they  are  large  enough  to  tit  the  passages  snugly  to  prevent 
entrance  of  air.  But  if  both  nostrils  are  occupied,  provision  must 
be  made  for  expired  breath  in  case  the  mouth  is  packed  with 
gauze  to  prevent  bleeding  into  the  throat. 

Recently  some  experimenters  have  taken  up  intratracheal  anes- 


CHOICE   OF   ANESTHETIC 


773 


thesia.  It  has  been  successfully  used  in  animal  surgery  for 
some  time,  and  the  tests  thus  far  made  by  Elsberg  and  others  seem 
to  indicate  that  it  may  be  used  with  equal  success  in  man.  A  silk- 
elastic  catheter  is  passed  nearly  to  the  bifurcation  of  the  trachea. 


Fig.  421. — Miller's  Apparatus  for  Vapor  Anesthesia.  The  bottle  is  a  modified 
atomizer  so  that  an  abundance  of  vapor  is  assured.  A  hollow  mouth  gag  and 
various  tips  for  use  in  the  nose  or  throat  are  shown. 

The  anesthetic  vapor  is  forced  into  the  lungs  in  a  constant  stream, 
and  a  very  slight  respiratory  movement  on  the  part  of  the  patient, 
suffices  to  expel  it  around  the  intratracheal  tube. 

With  the  forms  of  apparatus  now  on  the  market  for  giving 
vapor  anesthesia,  chloroform  vapor  with  a  slight  addition  of  ether 
is  probably  the  best  to  employ  in  operations  in  or  about  the  mouth, 
with  the  exception  perhaps  of  those  performed  for  enlarged  ade- 
noids and  tonsils,  ether  being  safer  than  chloroform  in  the  pres- 
ence of  a  marked  lymphatic  diathesis.    In  prolonged  and  difficult 


774  GENERAL   ANESTHESIA 

operations,  say  for  cancer  of  the  tongue  or  tonsil,  hypodermic 
anesthesia  offers  advantages.  It  wil]  sometimes  give  the  surgeon 
a  patient  whose  mouth  is  free  from  mucus,  who  Joes  not  vomit, 
whose  sensibility  is  so  reduced  thai  he  requires  little  or  no  addi- 
tional anesthetic,  who  can  open  his  mouth  or  turn  his  head  at  com- 
mand, and  who  after  the  operation  is  free  from  shock. 


CHAPTER    XXIV 

ADDITIONAL    SURGICAL    TECHNIQUE 

OPERATIONS  UPON  BLOOD  VESSELS 

WITHDRAWAL  OF  BLOOD  FOR  EXAMINATION 

In  most  cases  this  little  operation  is  easily  performed,  hut  at 
times  difficulties  are  encountered  which  render  some  rules  for  its 
correct  performance  desirable. 

Two  or  four  drams  of  blood  are  drawn  through  a  hollow  needle 


Fig.  422. — Withdrawal  op  Blood  from  a  Vein  for  Examination. 

into  a  clean  sterile  test  tube  or  small  wide-necked  bottle.  A  hol- 
low needle  about  the  size  of  the  lead  in  a  lead  pencil  is  boiled. 
A  prominent  vein  in  the  arm,  either  at  or  below  the  elbow,  is 

775 


776  ADDITIONAL  SURGICAL  TECHNIQUE 

chosen,  the  overlying  skin  cleansed  by  wiping  with  a  cotton  swab 
wet  with  alcohol,  and  a  tourniquet  placed  around  the  upper  arm. 
A  slender  rubber  tube  or  catheter  drawn  taut  about  the  arm  and 
caught,  with  an  artery  forceps  answers  perfectly.     (Fig,  422.) 

The  ligation  should  not  be  tight  enough  to  affect  the  arterial 
flow.  The  needle  with  its  opening  directed  toward  the  vein  is 
then  passed  very  obliquely  upward  into  the  vein.  This  move- 
ment should  be  made  promptly  but  steadily;  a  jab  will  probably 
miss  the  vein.  Failure  is  usually  due  to  the  passage  of  the  needle 
clear  through  the  vein.  While  the  skin  is  movable  over  the  huge 
veins,  the  distention  of  the  vein  brings  it  into  intimate  contact 
with  the  skin  and  obliterates  the  connective  tissue  space  between 
them.  The  point  of  the  needle,  therefore,  punctures  the  vein 
almost  as  soon  as  it  passes  the  skin   (Fig.  423). 


^5j^^SS^^^^^S?S^^w^2^w^1 


Fig.  423. — Needle  in  Position.  A,  correct  position  with  opening  parallel  to  vein; 
B,  incorrect  position,  in  which  it  is  difficult  to  make  the  lumen  of  the  needle 
match  that  of  the  vein. 


If  a  preliminary  injection  of  cocain  seems  necessary  on  ac- 
count of  the  timidity  of  the  patient,  the  amount  injected  should 
be  only  a  drop  or  two,  and  into  the  skin  rather  than  beneath  it. 
If  the  space  between  skin  and  vein  is  distended  with  the  injected 
fluid,  puncture  of  the  vein  is  more  difficult. 

In  very  stout  women  the  veins  are  so  inconspicuous  that  it 
may  be  necessary  to  puncture  one  at  the  elbow,  guided  only  by 
the  sense  of  touch.  Its  elasticity  and  compressibility  may  be 
recognized  although  the  vein  is  not  seen. 

If  a  patient  faints,  the  veins  collapse  with  the  fall  in  blood 
pressure  and  it  is  most  difficult  to  adjust  the  ligature  in  such  a 
manner  as  to  render  them  prominent.  If,  for  this  or  other  reason, 
puncture  is  impossible  the  skin  should  be  cocainized  and  a  short 


TRANSFUSION   OF   BLOOD  777 

incision  made,  the  vein  hooked  out  of  the  fat  with  a  ligature- 
carrier  or  some  other  curved,  blunt  instrument,  and  punctured 
under  the  guidance  of  the  eye. 

In  all  cases  as  soon  as  the  required  amount  of  blood  is  ob- 
tained the  tourniquet  should  first  be  released,  then  the  needle 
withdrawn  and  a  compress  applied  for  half  a  minute  to  the 
punctured  wound  to  prevent  subcutaneous  hemorrhage.  The  prick 
in  the  skin  should  then  be  touched  with  collodion. 

An  incised  wound  should  be  sutured  if  it  gapes  and  covered 

with  a  dry  dressing;  but  a  short  longitudinal  incision  will  require 

no  suture. 

DIRECT  BLOOD  TRANSFUSION 

Transfusion  of  blood  finds  its  chief  value  in  cases  in  which  the 
recipient  has  suffered  a  large  acute  hemorrhage  or  repeated  smaller 
ones.  Its  use  in  diseases  of  different  kinds  is  still  in  the  ex- 
perimental stage.  Transfusion  has  been  combined  with  blood- 
letting in  experiments  upon  animals ;  but  the  results  thus  far 
obtained  have  not  been  sufficiently  definite  to  warrant  its  em- 
ployment in  man  in  diseases  in  which  alterations  of  the  blood 
would  seem  to  make  it  desirable  to  draw  off  old  blood  and  replace 
it  with  new. 

The  technique  of  transfusion  has  been  variously  worked  out  by 
different  operators.  Anyone  intending  to  practice  it  should  first 
experiment  upon  dead  blood  vessels  and  then  upon  the  blood  vessels 
of  animals  before  attempting  to  turn  the  blood  stream  from  one 
vessel  to  another  in  human  subjects.  The  character  of  the  tissues 
operated  upon  is  such  that  general  surgical  skill  does  not  quite 
suffice;  but  even  an  hour's  practice  will  show  a  marked  improve- 
ment in  a  beginner's  delicacy  of  technique. 

The  usual  form  of  transfusion  is  from  an  artery  to  a  vein — 
generally  from  the  radial  artery  to  the  mediancephalic,  cephalic,  or 
other  vein  of  the  arm.  There  are  three  methods  of  connecting  these 
vessels  which  have  been  variously  employed  and  combined ;  namely, 
by  means  of  a  cannula,  by  suture,  and  by  invagination  of  the 
proximal  end  of  the  artery  into  the  proximal  or  distal  end  of 
the  vein.  Whatever  the  method  employed,  injury  to  the  blood 
vessels,  long  exposure  to  the  air,  and  other  steps  which  facilitate 
clotting  of  the  blood  should  be  avoided.  For  this  reason  the  use 
of  a  cannula  and  direct  suture  of  artery  to  vein  are  less  to  be 


778 


ADDITIONAL   SURGICAL  TECHNIQUE 


recommended  than  the  method  of  invagination,  which  is  per- 
formed as  follows : 

The  wrist  of  the  donor  and  the  arm  of  the  recipient  should 
be  scrubbed  with  soap,  water,  and  alcohol. 

The  radial  artery  should  be  exposed  for  a  distance  of  two 


Fig.  424. — Radial  Artery  Exposed,  Stripped  of  its  Adventitia,  Clamped  Below, 
and  Divided  Ready  for  Insertion  into  the  Vein.     (Deavor's  Method.) 


inches,  stripped  of  its  adventitia  to  reduce  its  size  and  increase 
its  firmness,  and  covered  with  a  warm,  moist  saline  compress 
(Fig.  424). 

A  ligature  is  placed  around  the  upper  arm  of  the  recipient 
tight  enough  to  distend  the  veins.  The  vein  selected  is  exposed 
by  a  longitudinal  incision  for  an  inch  or  more,  brought  to  the 
surface  and  fixed  with  two  fine  clamping  mouse-tooth  forceps 
placed  side  by  side,  so  that  when  the  vein  is  opened  longitudinally 
between  them  they  will  control  the  cut  edges  (Fig.  425). 


TRANSFUSION  OF   BLOOD 


779 


The  ligature  is  next  removed  from  the  arm  and  the  vein 
is  opened  for  an  inch  or  less.  The  artery  is  divided,  its  <listal 
end  clamped  and  its  proximal  end  seized  with  fine  thumb  forceps 
(Fig.  424).  While  the  blood  is  streaming  from  it,  it  is  passed 
upward  into  the  vein  about  an  inch,  just  as  one  inserts  a  rubber 
drainage  tube  into  a  sinus. 
The  two  forceps  upon  the 
vein  are  crossed,  thus  lap- 
ping the  edges  of  the  vein 
around  the  invaginated  artery 
tight  enough  to  prevent  the 
escaj)e  of  blood. 

If  one  wishes  to  estimate 
the  amount  of  blood  passed 
to  the  recipient,  a  certain 
number  of  spurts  from  the 
cut  artery  should  be  caught 
in  a  measuring  glass  before 
the  vessel  is  inserted  into  the 
vein.  The  pulse  of  the  donor 
should  then  be  counted  ,as 
long  as  the  transfusion  con- 
tinues, and  in  this  manner  a 
fairly  accurate  estimate  is 
made  of  the  total  amount  of 
the  transfused  blood. 

This  technique,  suggested 
by  Deavor,  of  Syracuse,  is  so 
simple  that  it  is  difficult  to 
see  how  it  can  be  improved 
upon. 

Greasing  of  the  cut  end  of  the  artery  and  a  special  clamp  to 
compress  the  end  of  the  artery  while  inserting  it  into  the  vein 
have  been  suggested,  but  these  means  are  unnecessary.  When  the 
transfusion  is  finished  the  artery  is  withdrawn,  ligated,  and  the 
wound  sutured.  The  opening  in  the  vein  may  be  closed  by  liga- 
tures or  a  suture  or  simply  by  pressure  after  suture  of  the  skin. 

Our  knowledge  of  the  amount  of  blood  which  should  be  trans- 
fused is  not  very  definite.      Clinically  the  practice  has  usually 


Fig.  425. — Cephalic  Vein  Exposed,  Clamped 
and  Incised,  Ready  to  Receive  the 
Radial  Artery.     (Deavor's  Method.) 


780 


ADDITIONAL  SURGICAL  TECHNIQUE 


been  to  continue  the  transfusion  for  half  an  hour  or  more  until 
the  pulse,  blood  pressure,  and  other  symptoms  showed  a  material 
change  in  the  donor  or  recipient,  or  both.  It  is  safe  to  employ 
from  eight  to  twelve  ounces  at  one  time.  If  more  is  used  the 
recipient  should  be  carefully  watched  for  sudden  changes  in  the 
pulse,  embarrassment  of  respiration,  or  nervous  irritability;  for 
the  danger  of  a  large  overdose  of  transfused  blood  is  far  greater 
than  that  of  an  overdose  of  transfused  saline  solution. 


INJECTION  OF  SALVARSAN 

Salvarsan  is  generally  injected  into  a  vein.     Neosalvarsan  is 
similarly  employed.     On  account  of  its  readier  solubility  it  is 

sometimes  injected 
into  the  deeper  tis- 
sues of  the  buttocks, 
but  such  injection 
is  not  without  risk, 
since  it  may  produce 
a  dry  gangrene  — 
possibly  reaching  to 
the  skin  (Fig.  426). 
The  wide  use  of 
salvarsan  has  led  to 
the  manufacture  of 
a  great  variety  of 
special  instruments 
for  its  intravenous 
introduction.  While 
many  men  exhibit  a 
preference  for  spe- 
cial apparatus  for  a 
particular  purpose, 
the  technique  of  the 
intravenous  injec- 
tion of  salvarsan  is 
essentially  the  tech- 
nique of  transfusion.  On  account  of  the  irritation  of  the  salvarsan 
solution  in  subcutaneous  tissue  one  must  be  careful  not  to  permit 


Fig.  426. — Gangrene  Following  Injection  of  Neo- 
salvarsan.  Three  longitudinal  incisions  are  seen 
but  no  pus  was  obtained.  This  patient  had  previous 
injection  without  bad  result. 


INJECTION   OF  SALVARSAN 


781. 


its  escape  outside  the  vein.    Hence  it  is  advisable  to  begin  and  cud 
the  injection  with  normal  saline  solution. 

One  may  follow  the  technique  given  on  page  584,  or  may  simply 
puncture  the  vein  in  the  manner  described  on  page  775,  remove 
the  tourniquet  and  start  the  injection.  No  special  apparatus  is 
needed.  The  salvarsan  or  neosalvarsan  should  be  mixed  according 
to  directions  in  a  graduate 
Only  a  glass  funnel  with 
three  feet  of  rubber  tubing,  a 
glass  connecting  rod,  and  an 
inch  of  rubber  tubing  to  make 
connection  with  the  hollow 
needle  are  required  (Fig.  427). 

When  all  is  ready  the 
vein  is  punctured,  a  specimen 
of  blood  taken  if  desired,  and 
the  tourniquet  removed.  Sa- 
line solution  is  poured  into 
the  funnel  and  allowed  to  run 
through  the  tube.  While  it 
is  still  running  connection  is 
made ;  and  the  fact  that  it 
runs  smoothly  into  the  vein 
must  be  established,  more 
saline  being  poured  into  the 
funnel  if  necessary  to  prove 
this  absolutely.  Then,  before 
the  funnel  is  empty,  the  sal- 
varsan is  poured  into  it  fast 
enough  to  keep  some  fluid  always  in  the  funnel.  Just  before 
the  salvarsan  has  all  escaped  from  the  funnel  it  is  followed  with 
enough  saline  to  make  sure  that  all  the  salvarsan  has  passed 
through  the  tube  into  the  vein.  Pressure  is  then  made  above 
the  puncture  and  the  needle  is  quickly  withdrawn.  Pressure  is 
continued  by  a  compress  and  bandage  for  a  few  minutes,  and.  if 
the  skin  was  incised,  the  dressing  is  left  in  place. 

The  technique  is  so  simple  that  salvarsan  is  often  given  in  a 
doctor's  office  and  the  patient  allowed  to  go  home.  It  is  not 
intended  here  to  do  more  than  describe  the  technique  of  injection, 


Fig.  427. — Simple  Apparatus  for  Saline 
Transfusion  or  the  Injection  of 
Salvarsan. 


782  ADDITIONAL   SURGICAL  TECHNIQUE 

but  ii  should  u. ii  be  forgotten  that  the  use  of  this  powerful  drag 
sometime-  causes  serious  symptoms  and  has  caused  death.  What- 
ever may  be  thought  of  its  office  use  in  general,  it  certainly  should 
not  be  so  employed  with  persons  who  show  signs  of  status  lymphati- 
cus  or  disease  of  the  central  nervous  system  or  of  other  important 
organs.;  and  any  person  receiving  an  injection  should  immediately 
go  home  and  to  bed. 

OPERATIONS   UPON   NERVES 
INJECTIONS    OF    ALCOHOL    FOR    NEURALGIA 

The  treatment  of  neuralgia  by  injections  of  alcohol  into  the 
trunk  of  a  nerve  has  become  firmly  established.  Two  c.  em. 
(30  m.)  of  DO  per  cent,  alcohol  will  produce  an  anesthesia  lasting 
for  weeks  or  months.  The  nerves  upon  which  this  treatment  has 
most  often  been  employed  are  the  second  and  third  branches  of 
the  fifth  cranial,  and,  as  the  technique  is  similar  for  other  nerves, 
it  must  suffice  to  describe  the  injection  of  these  two  branches. 

Before  making  injection  one  should  be  sure  of  the  existence 
of  neuralgia  as  differentiated  from  other  pains.  As  chief  charac- 
teristics of  true  neuralgia  it  may  be  noted  that  the  pain  always 
begins  in  a  distinct  point  and  radiates  only  to  the  area  of  distri- 
bution of  the  affected  nerve.  It  is  paroxysmal  in  type,  recurs  in 
the  same  situation,  and,  after  the  disease  is  chronic,  the  pain  can 
be  started  by  some  slight  stimulus  in  the  affected  area,  such  as 
a  light  touch  to  the  face. 

The   instruments   required   for  injection   are   a   glass  syringe 


~> '     ■  ' -■ ■--■  =^ 


Fig.  42S. — Syringe  and  Stylet  and  Needle  for  Trifacial  Injection.  (Patrick.) 

holding  2  c.  cm.  (30  minims)  fitted  without  thread  to  a  needle  10 
or  12  cm.  (4  or  5  in.)  long  with  a  caliber  of  1.5  or  1.8  mm.  (about 
1-16  in.)  and  having  a  rather  blunt  point.  The  needle  should  be 
fitted  with  a  stylet  of  such  a  length  that  when  pushed  home  it 
just  blocks  the  point  of  the  needle  (Fig.  428). 


INJECTIONS  FOR  NEURALGIA 


783 


The  needle  should  be  marked   in  centimeters  or  fractions  of 
an  inch  up  to  G  cm.   (2-J  in.).     The  solution   used    for  injection 

may  be  70  or  SO  or  U0  per  cent,  alcohol  in  water,  with  or  without 
a  little  cocain.    II.  T.  Patrick,  of  Chicago,  who  has  probably  made 
more  injections  than  anyone  else  in  this  country,  now  uses  rather 
a' weaker  formula,  viz.,  eoeain,  gr.  ii ;  alcohol,  Siiiss;  water,  3i. 
The  second  or  superior  maxillary  branch  of  the  5th   cranial 


Fig.  429. — Showing  the  Points  of  Insertion  of  the  Needle  in  Relation  to  the 
Bones  of  the  Face:  2,  to  Reach  the  Superior  Maxillary  Nerve,  and  3, 
to  Reach  the  Inferior  Maxillary  Nerve.     (Patrick.) 


nerve  leaves  the  skull  through  the  foramen  rotundum.  It  can  be 
reached  in  front  of  the  eoronoid  process  of  the  lower  jaw,  just  under 
the  zygoma  (Fig.  429,  point  2).  Deep  pressure  with  the  tip  of  the 
little  finger  made  by  the  operator  upon  his  own  face  at  this  point 
will  give  him  some  appreciation  of  the  situation  of  this  nerve.  To 
reach  it  the  needle  should  be  passed  inward  and  a  little  upward  to 
a  depth  of  5  cm.  (2  in.)  (Figs.  430  and  431).  ~No  local  anesthetic 
is  needed,  and  a  general  anesthetic  makes  it  impossible  for  the 
patient  to  tell  the  operator  when  the  needle  touches  the  nerve. 
The  skin  may,  however,  be  cocainized.     The  point  of  insertion 


Figs.    430    and    431. — Needle     Inserted     for    Injection     of    the     Superior 
Maxillary    Nerve.     Side   and    front    views.     (Patrick.) 


784 


INJECTIONS  FOR  NEURALGIA  785 

having  been  settled,  the  empty  needle  is  passed  through  the  skin 
and  the  stylet  is  then  introduced  to  lessen  the  risk  of  puncture  of 
a  vessel.  The  needle  is  then  slowly  passed  until  bone  is  touched 
or  tingling  or  pain  in  the  area  of  distribution  of  the  superior 
maxillary  nerve  shows  that  ils  trunk  lias  beeu  touched.  Bone 
touched  at  less  than  two  inches  is  probably  the  posterior  margin 
of  the  superior  maxilla.  In  some  cases  a  better  access  to  the  nerve 
is  obtained  if  the  patient  opens  his  mouth. 

If  the  nerve  is  not  touched  the  needle  should  be  withdrawn  a 
little  way  and  again  pushed  in  a  little  to  one  side  or  the  other 
of  its  former  position.  This  causes  very  little  pain  and  there  are 
no  important  structures  to  be  injured  in  the  immediate  vicinity. 
If  repeated  sounding  fails  to  touch  the  nerve  the'  injection  of  a 
drop  or  two  of  the  alcoholic  solution  may  produce  the  tingling 
sensation  sought  for,  but  the  results  are  not  likely  to  be  so  good  as 
when  the  patient  recognizes  that  the  needle  point  has  pricked  the 
nerve. 

When  the  needle  is  in  place  the  stylet  is  withdrawn,  the  syringe 
attached,  and  the  full  2  c.  cm.  (30  m.)  of  the  alcoholic  solution 
are  injected  and  should  produce  an  almost  instant  anesthesia  over 
the  whole  area  of  distribution  of  the  nerve.  The  needle  is  then 
withdrawn,  the  puncture  touched  with  collodion,  and  a  few  min- 
utes later  the  patient  is  allowed  to  get  up. 

Variations  in  the  shape  and  position  of  the  zygoma  and  coro- 
noid  process  may  make  it  necessary  to  insert  the  needle  above  the 
zygoma  or  behind  the  coronoid  process.  In  the  former  case  the 
needle  must  be  directed  downward,  and,  in  the  latter,  well  for- 
ward, to  make  allowance  for  the  change  in  the  point  of  entrance. 

If  no  immediate  anesthesia  follows  injection  it  must  be  looked 
upon  as  a  failure  and  another  attempt  should  be  made  in  a  day  or 
two.  Even  those  most  familiar  with  the  technique  report  that  they 
often  fail  to  reach  the  nerve  by  the  first  injection ;  while  in  a  con- 
siderable number  of  cases — probably  more  than  25  per  cent. — 
repeated  injections  are  unsuccessful.  However,  the  patient  has 
little  to  lose  by  the  trial  and  everything  to  gain  if  it  succeeds. 
When  a  marked  anesthesia  is  produced  which  lasts  two  or  three 
days  there  may  be  expected  relief  from  pain  lasting  from  six 
months  to  four  years. 


Figs.  432  and  433. — Showing  the  Point  of  Insertion  and  Direction  of  the 
Needle  for  Injection  of  the  Inferior  Maxillary  Nerve.  Side  and  front 
views.     (Patrick.) 


786 


VACCINE  THERAPY  787 

The  injection  of  the  inferior  maxillary  nerve  is  similar  to  that 
of  the  superior  maxillary  nerve  described  above.  The  point  of 
entrance  is  shown  at  3  in  Figure  429.  The  needle  is  directed 
very  slightly  upward  and  a  little  backward  (Figs.  4.32  and  43:5; 
a  distance  of  4  cm.  (just  under  2  inches). 

If  the  needle  touches  bone  at  less  than  two  inches  it  is  prob- 
ably the  external  plate  of  the  pterygoid.  One  feels  his  way  back- 
ward along  this  bone  till  the  nerve  is  reached. 

Many  operators  have  given  precise  anatomical  directions  for 
these  injections,  but  variations  in  the  human  skull,  and  the 
fact  that  exact  measurements  are  impossible  from  bony  points 
covered  with  flesh,  make  such  directions  of  little  use.  Practice 
on  the  cadaver  is  a  good  preparation,  but,  no  matter  what  the  ex- 
perience, one  must  feel  his  way  to  the  nerve  in  making  the  actual 
injection. 

Peripheral  branches  of  the  fifth  cranial  nerve,  or  other  sensory 
nerves  of  the  body  which  are  subject  to  distinct  neuralgic  attacks, 
may  be  treated  by  alcoholic  injections,  but,  on  account  of  the  risk 
of  paralysis,  nerves  which  contain  important  motor  fibers  should 
not  be  thus  treated. 

VACCINE  THERAPY— SERUM  THERAPY 

Interest  in  vaccine  therapy  and  serum  therapy  is  to-day  wide- 
spread. The  aid  of  bacterial  laboratory  products  is  so  often 
sought  in  surgical  conditions  that  every  doctor  should  be  familiar 
with  the  necessity  for  and  the  method  of  their  administration. 
The  term  serum  therapy  has  been  rather  carelessly  employed  to 
cover  the  use  of  any  remedy  directly  or  remotely  connected  with 
a  micro-organism.  Without  going  into  details  of  the  preparation 
of  these  remedies  it  is  evident  that  they  must  be  divided  at  least 
into  two  classes;  namely,  vaccines,  that  is  to  say,  fluids  containing 
live  bacteria  or  dead  bacteria  or  some  of  the  chemical  products 
(toxins)  of  bacteria ;  and  serums  taken  from  horses  or  other  ani- 
mals after  they  have  received  injections  of  some  vaccine  long 
enough  to  develop  some  protective  changes  in  their  blood. 

These  two  classes  of  remedies  are  so  distinct  that  no  intelli- 
gent person  ought  to  confound  them.  They  are  just  as  distinct  as 
an  ax  is  distinct  from  a  pile  of  stovewood  all  cut  and  ready  for 


r.SS  ADDITIONAL  SURGICAL  TECHNIQUE 

use.  Either  may  save  a  man  from  freezing  to  death.  But,  in  the 
case  of  the  ax,  as  in  the  ease  of  the  vaccine,  he  has  to  provide  his 
own  protection;  while  the  serum,  like  the  stovewood,  is  protection 
ready  made,  although  the  probability  exists  that  it  may  also  stimu- 
late the  recipienl  to  some  protective  exertions  of  his  own. 

The  protection  against  disease  is  spoken  of  as  immunity. 
When  it  is  obtained  through  use  of  a  vaccine  it  is  called  active 
immunity ;  and  if  it  follows  the  use  of  a  serum  it  is  called  passive 
in  mi  unity.  It  is  supposed  to  be  due  to  the  existence  in  the  blood 
and  Other  fluids  and  tissues  of  the  body  of  certain  substances  called 
antibodies,  which  either  destroy  bacteria  or  render  them  harmless 
or  neutralize  their  poisons. 

If  a  vaccine  is  used  these  antibodies  must  be  developed  by  the 
individual.  If  a  serum  is  used  the  antibodies  are  introduced  with 
the  serum,  having'  been  previously  developed  in  the  animal  from 
which  the  serum  was  taken. 

In  selecting  the  vaccine  to  be  employed  it  seems  natural  to 
choose  one  derived  from  the  same  bacterium  as  that  which  is  at- 
tacking- the  patient.  For  instance,  if  the  person  is  suffering  from 
a  series  of  boils,  one  may  isolate  the  organisms  of  a  freshly  opened 
pus  focus  and  culture  the  prevailing  bacteria  to  produce  the  vac- 
cine. This  is  then  called  an  autogenous  vaccine.  Or,  to  save  ex- 
pense or  delay,  one  may  only  determine  the  species  of  organism 
present  (probably  the  staphylococcus  aureus  in  the  example  cited) 
and  buy  of  the  druggist  a  vaccine  previously  made  from  other 
strains  of  this  germ.  Still  a  third  plan  is  to  employ  a  vaccine 
made  from  cultures  of  several  kinds  of  bacteria  capable  of  pro- 
ducing lesions  similar  to  those  from  which  the  patient  is  suffering. 
Such  a  vaccine  is  technically  called  "  polyvalent."  Whether  or 
not  its  value  is  increased  on  account  of  the  different  species  of 
bacteria  which  are  contained  in  it  is  still  an  unsettled  problem. 
Bacteriologists  and  clinicians  who  have  given  much  study  to  vac- 
cine therapy  are  almost  unanimously  in  favor  of  autogenous  vac- 
cines whenever  they  can  be  obtained.  Sometimes  a  polyvalent  vac- 
cine contains  only  one  bacterial  species,  but  a  mixture  of  strains 
of  this  species  obtained  from  different  individuals  having  the  same 
disease. 

While  different  forms  of  vaccine  may  be  prepared  the  only 
kind  in  general  use  is  a  suspension  in  normal  saline  solution  of 


VACCINE  THERAPY  789 

bacteria  killed  by  heat,  to  which  a  small  amount  of  some  anti- 
septic, usually  one  of  the  phenols,  is  added  as  a  preservative. 
It  is  standardized  by  estimating  the  number  of  bacteria  per  c.  c. 
and  diluting  it  to  the  required  strength.  The  dosage  of  'lend 
bacteria  employed  often  runs  into  the  millions. 

Vaccines  are  given  subcutaneously ;  preferably  with  a  glass 
hypodermic  syringe  and  fine  steel  needle.  The  ordinary  Sub-Q. 
syringe  answers  every  purpose.  Syringe  and  needle  should  be 
sterilized  by  boiling,  and  well  rinsed  after  use.  A  little  alcohol 
sucked  up  into  the  needle  before  it  is  disconnected  from  the  syringe 
will  delay  rusting.  It  is  well  to  keep  a  special  syringe  and  several 
needles  simply  for  vaccine  injection. 

As  the  bacterial  suspension  always  settles,  the  bottle  should 
be  well  shaken  before  the  fluid  is  drawn  into  the  syringe. 

The  site  of  injection  should  be  one  which  permits  easy  disten- 
tion of  the  tissues  and  is  not  likely  to  be  pressed  upon.  The 
upper  arm,  the  region  below  the  scapula,  or  the  clavicle,  the  side 
of  the  chest  or  the  buttock  may  be  chosen.  The  needle  should 
be  plunged  well  through  the  skin  so  that  the  injection  shall  be 
made  into  loose  connective  tissue.  Repeated  injections  should 
not  be  given  in  the  same  area. 

If  the  fluid  does  not  quickly  diffuse  through  the  tissues  light 
massage  is  advisable.  If  a  vein  is  punctured  and  blood  escapes 
subcutaneously  immediate  massage  is  not  advisable  as  it  might 
increase  the  bleeding. 

The  local  reaction  following  injection  is  usually'  slight  and 
no  dressing  is  needed.  If  a  painful  red  swelling  results  a  wet 
dressing  gives  relief.  The  possibility  of  infection  and  formation 
of  an  abscess  should  be  kept  in  mind  after  any  injection,  and,  if 
the  characteristic  signs  appear  two  or  more  days  later,  incision 
and  drainage  should  not  be  long  delayed. 

In  successful  vaccination  there  is  a  "  negative  phase  "  lasting 
a  day  more  or  less,  followed  by  a  "  positive  phase  "  lasting  for 
several  days.  These  phases  are  marked  by  changes  in  the  opsonic 
index  of  the  patient's  blood  and  also  by  clinical  symptoms.  Thus 
during  the  day  following  the  injection  there  are  likely  to  be  ano- 
rexia, malaise,  headache,  and  a  higher  temperature  with  increased 
pain  and  swelling  in  the  area  of  infection.  The  following  day, 
or  when  the  positive  stage  develops,  the  patient  feels  distinctly 


790  ADDITIONAL  SURGICAL  TECHNIQUE 

better  and  there  is  subsidence  of  the  infection,  as  shown  by  less 
pain  and  by  less  discharge  from  the  wound,  if  such  exists. 

The  chief  use  of  vaccine  therapy  in  minor  surgery  is  to  limit 
the  spread  of  infections.  An  agent  capable  of  checking  the 
spread  of  an  acute  cellulitis  of  the  hand,  for  example,  would  be 
of  untold  value  Unfortunately,  in  these  acute  cases  it  is  often 
difficult  to  determine  promptly  the  exact  organism  at  work,  and, 
where  this  is  known  and  a  vaccine  prepared,  it  is  equally  difficult 
to  decide  upon  the  dosage  which  will  best  aid  the  body  in  its 
defence.  To  conclude,  as  some  have  done,  that  vaccines  have  no 
place  in  the  treatment  of  acute  suppurative  infections  is  going  too 
far;  but  they  should  be  used  with  greal  caution  and,  above  all, 
one  should  not  expect  them  to  take  the  place  of  free  drainage — 
for  this  still  holds  the  first  place  in  our  treatment. 

The  dosage  of  bacteria  in  vaccine  therapy  ranges  from  50 
million  to  1,000  million  or  more.  Only  experience  will  enable  the 
administrator  to  judge  of  the  amount  probably  required  to  pro- 
duce the  best  results.  An  overdose  gives  a  prolonged  "negative 
phase  "  with  too  great  depression  and  the  beneficial  reaction  is 
unduly  delayed  or  does  not  occur.  An  insufficient  dose,  or  a 
dosage  of  bacteria  not  suited  to  the  case,  gives  a  transient  negative 
phase  followed  by  little  or  no  improvement.  If  repeated  and  in- 
creased doses  fail  to  give  relief  it  is  unwise  to  continue  a  treat- 
ment which  simply  gives  a  patient  other  poisons  to  eliminate. 

In  the  treatment  of  chronic  or  recurrent  boils  a  vaccine  of  the 
yellow  pus  staphylococcus  has  proved  most  efficacious.  Infections 
due  to  the  deadlier  streptococcus  are  less  amenable  to  treatment  by 
vaccine — even  when  a  reliable  autogenous  preparation  is  available ; 
but  enough  good  results  have  been  obtained  to  warrant  giving  both 
stock  and  autogenous  preparations  a  trial. 

We  may  sum  up  our  present  knowledge  of  vaccine  therapy, 
as  far  as  its  applicability  in  surgical  infections  is  concerned,  by 
saying  that  is  a  method  of  treatment  which  has  at  times  proved 
beneficial  but  which  is  still  in  the  experimental  stage.  It  should 
only  be  used  to  supplement  surgical  measures — never  to  supplant 
them. 


INDEX 


INDEX 


Abdomen,  auscultation  of,  155. 
contusion  of,  154. 
symptoms  of,  154. 
treatment  after,  156. 
descending  spiral  bandage  of,  641. 
many  tailed  bandage  of,  642. 
melanosarcoma  of,  191. 
penetrating  wound  of,  158. 
testicle  within,  254. 
Abdominal  rigidity  after  injury,  155. 
Aberrant  thyroid  in  skull,  105. 
Abrasions,  wet  dressing  for,  7. 
Abrasions  of  the  face,  7. 

of  the  scalp,  7. 
Abscess,  alveolar,  39. 

imperfect  drainage  in,  44. 
incision  for,  46. 
location  of,  39. 
scar  from,  47. 
treatment  for,  45. 
axillary,  429. 
"collar-button,"  405. 
drainage  of,  576. 
from  pediculi,  130. 
in  cellulitis,  402. 
in  tonsillitis,  55. 
irrigation  of,  576. 
ischiorectal,  291. 
drainage  of,  294. 
operation  for,  294. 
rupture  of,  293. 
symptoms  of,  292. 
treatment  of,  293. 
mammary,  173. 
of  anus,  291. 
of  breast,  drain  for,  173. 

hot  wet  compresses  for,  173. 
incision  for,  173. 
of  external  genitals,  212. 
of  face,  38. 
of  finger,  405. 


Abscess,  of  foot,  518. 

of  forearm,  422. 

of  leg,  517. 

of  lip,  38. 

of  little  finger,  incision  for,  417. 

of  neck,  130. 
deep,  131. 

of  pharynx,  incision  for,  56. 

of  rectum,  291. 

of  scalp,  38. 

of  scrotum,  212. 

of  tip  of  thumb,  406. 

of  tongue,  38. 

of  wrist,  incision  for,  417. 

opening  of,  575. 

perirectal,  291. 

peritonsillar,  55. 

retropharyngeal,  56. 

section  of  finger  showing  sites  of,  406. 

treatment  of,  38. 

under  sternomastoid  muscle,  131. 
Abscess  cavity,  drainage  of,  419. 
Absence  of  anus,  323. 
Absorbable  sutures,  690. 
Absorbent  cotton,  681. 
Absorbent  gauze,  683. 
Accessory  tendons,  resection  of,  470. 
Acne,  treatment  for,  33. 
Acne  of  the  face,  32. 
Acne  rosacea,  operation  for,  85. 
Acquired  deformities    of   female  geni- 
tals, 272. 

of  foot,  543. 

of  hand,  463. 

of  neck,  147. 
Actinomycosis  of  the  face,  65. 
Action  of  the   flexors  of  the  fingers, 

329. 
Active  motions  after  fracture,  370. 

after  sprain,  339. 
Acute  conjunctivitis,  47. 
793 


794 


INDEX 


Adenoids,  86. 

operation  for,  89. 
Adenoma  of  breast,  183,  187. 
Adhesions  of  foreskin,  245. 

of  the  clitoris,  277. 
Adhesive  plaster  strapping,  for  broken 
rib,  168. 

for  fracture  of  the  patella,  499. 

for  hammer-toe,  555. 

for  sprain  of  ankle,  494. 

for  sprain  of  back,  159. 

for  sprain  of  thumb,  340. 
Air-passages,  suture  of  wounds  of,  119. 
Alcohol,    injections    of,   for  neuralgia, 

782. 
Aluminum  acetate  for  burns,  27. 

bronze  wire,  694. 

splints,  698. 
Alveolar  abscess,  39. 
Amputation  for  frost-bite,  394. 

for  hammer-toe,  556. 

of  a  finger,  390. 

of  toes,  510. 

of  uvula,  111. 
Anastomosis  of  blood  vessels,  777. 
Anatomical  tubercle,  399. 
Anesthesia,  714. 

acid  intoxication  from,  736. 

apparatus  for,  740,  745,  756,  761,  773. 

complications  of,  723,  727,  736,  747, 
750,  760,  770. 

contraindications  to,  743,  754,  762. 

deaths  from,  734,  743,  762,  764. 

discovery  of,  739,  748,  764. 

general,  714. 

hypodermic,  763. 

in  children,  715. 

in  diagnosis  of  fractures,  368. 

in  oral  surgery,  772. 

induction  of,  719,  749. 

local,  566. 

oxygen  in,  731,  744,  747. 

preliminary  medication  in,  719,  768. 

preparation  for,  716. 

records  of,  737. 

recovery  from,  731. 

rectal,  764. 

respiration  in,  720,  722,  728,  742. 

signs  of,  721,  749. 

shock  in,  728,  733,  769. 

spinal,  583,  765. 


Anesthesia,    status    lymphatieus    and, 
735,  772. 

vapor  method  of,  752,  757,  772. 

vomiting  from,  725,  732,  74*). 
Anesthetics,     administration    of,    742, 
750,  755. 

chloroform,  754,  760. 

choice  of,  769. 

ether,  748,  754. 

ethyl  chlorid,  761. 

mixed,  762. 

nitrous-oxid  gas,  739. 

oil-ether,  765. 

somnaform,  762. 
Anesthetist,  qualifications  of,  715. 
Aneurism  of  hand,  448. 

of  leg,  540. 

of  the  popliteal  artery,  540. 
Angina  Ludovici,  131. 
Angioma,  capillary,  80. 

electrolysis  for,  81. 

injection  of  boiling  water  for,  81 

pulsating,  of  scalp,  82. 
Angiosarcoma  of  the  jaw,  106. 
Animal  tendons,  692. 
Animal,  bites  of,  328. 
Ankle,  figure  of  eight  bandage  of,  671. 

fractures  involving,  504. 

sprain  of,  493. 

recurrent,  496. 

with  fracture,  495. 
Anthrax,  of  face,  59. 

of  neck,  132. 
Antiseptic  dressing  for  burns,  28. 
Antrum  of  Highmore,  drainage  of,  54. 
Anus,  abscess  of,  291. 

absence  of,  323. 

cancer  of,  316. 

care  of,  290. 

chancroids  about,  299. 

deformities  of,  318,  322. 

dilatation  of,  283,  287. 

examination  of,  280. 

fissure  of,  289. 

fistula  of,  295. 

hemorrhage  from,  284. 

imperforate,  322. 

inflammations  of,  286. 

injuries  of,  280. 

itching  about,  287. 

mucous  patches  of,  300. 


INDEX 


795 


Anus,  pointed  condylomata  of,  307. 

polyp  of,  308. 

syphilitic  condylomata  of,  300. 

tumors  of,  307. 

venereal  warts  about,  307. 

wounds  of,  284. 
Application  of  a  bandage,  590. 

of  a  gypsum  bandage,  703. 

of  plaster  cast,  703. 
Applications  for  fissure,  290. 
Arm,  arterial  aneurism  of,  448. 

bandages  of,  643. 

boil  of,  404. 

deforming  arthritis  of,  434. 

furuncle  of,  404. 

hematoma  of,  325. 

injuries  of,  324. 

lipoma  of,  451. 

lymphadenitis  of,  429. 

lymphangitis  of,  428. 

multiple  lipomata  of,  452. 

neuritis  of,  342. 

neurofibroma  of,  455. 

osteomyelitis  of,  443. 

spiral  bandage  of,  644. 

tuberculosis  of  joints  of,  440. 

tumors  of,  445. 
Arm  and  hand,  burns  of,  393. 

dislocation  of,  347. 

treatment  for  wounds  of,  330. 
Arsenious  acid  for  epithelioma,  104. 
Arterial  anastomosis,  777. 
Arterial  aneurism  of  arm,  448. 
Artery,  division  of  radial,  328. 
Arthritis,  gonorrheal,  433. 

of  arm,  deforming,  434. 

of  hand,  suppurative,  423. 

of  neck,  deforming,  134. 

suppurative,  with  loss  of  bone,  424. 

rheumatoid,  434. 

tuberculous,  treatment  for,,  443. 
Articular  rheumatism,  433. 
Ascending    spica    bandage,     of    both 
groins,  659. 

of  buttock,  661. 

of  one  groin,  657. 

of  shoulder,  643. 
Ascending  spiral  bandage  of  abdomen, 

642. 
Ascites,  199. 
Asepsis,  563. 


Aspiration  and  injection  for  hydrocele, 

239. 
Aspiration  of  bladder,  220. 
of  fluid  from  joint,  484. 
Astragalus,  IVii.ft.urf  of,  507. 
Astringent    applications    for    inconti- 
nence of  urine,  272. 
Astringent  douches  in  leucorrhea,  265. 
Astringents    for    relaxation    of   uvula, 
111. 
in  gonorrhea,  215. 
Atrophy  of  the  deltoid  following  injury, 

342. 
Auscultation  of  abdomen,  155. 
Autoinfection  in  gonorrhea,  49. 
Axilla,  complete  bandage  of,  623. 
lymphadenitis  of,  429. 
palpation  of,  189. 

suppurating  glands  of,  incision  for, 
430. 
Axilla?,    figure    of    eight    bandage    of 

both,  618. 
Axillary  abscess,  429. 

Back,  adhesive  plaster  for  sprain  of, 
159. 

contusions  of,  154. 

epithelioma  of,  190. 

fibrolipomata  of,  185. 

gunshot  wound  of,  156. 

lupus  of,  178. 

sprain  of,  158. 

treatment  for  sprain  of,  158. 
Balanitis,  210. 

circumcision  for,  211. 
Bandage,  amount  of  pressure  of,  593. 

application  of,  590. 

black,  688. 

completion  of,  594. 

crinoline,  688. 

effect  of,  on  circulation,  594. 

extremity  of,  589. 

figure  of  eight  turn  of,  592. 

flannel,  686. 

for  fractured  jaw,  21. 

gauze,  685. 

gypsum,  700. 

how  to  fasten,  594. 

initial  extremity  of,  589. 

muslin,  686. 

of  plaster  of  Paris,  700. 


796 


iNDi:x 


Bandage  of  silk  ribbon,  688. 

overlapping  turns  of,  591. 

preparation  of,  588. 

reverse  of,  590. 

rubber,  688. 

spica,  593. 

spiral  reverse,  590. 
Bandages,  of  arm,  643. 

gauze  for,  683. 

of  head,  595. 

of  neck  and  axilla,  613. 

of  lower  extremity,  657. 

of  trunk,  626. 

of  upper  extremity,  643. 
Bartholin's  gland,  eyst  of,  270. 

incision  for  suppuration  in,  264. 

inflammation  of,  263. 
Barton's  bandage  of  lower  jaw,  609. 
Baseball  finger,  361. 
Bed,  wetting  of,  220. 
Bedbugs  and  fleas,  bites  of,  171. 
Bed-sore,  treatment  for,  175. 
Benign  tumors  of  external  genitals  of 

female,  270. 
Biceps  muscle,  rupture  of,  327. 
Birth,  hernia  at,  194. 
Bites,  of  animals,  328. 

of  fleas  and  bedbugs,  171. 

of  insects,  171. 
Bivalve  rectal  speculum,  283. 
Black  bandage,  688. 
Black  eye,  treatment  for,  2. 
Blackhead,  66. 

Bladder,   affection    of,   in    gonorrhea, 
215. 

aspiration  of,  220. 

astringent  applications   for  inconti- 
nence of,  272. 

calculus  due  to  foreign  body  in,  208. 

catheter  in,  209. 

exstrophy  of,  252. 

foreign  bodies  in,  208,  259. 

relaxation  of  sphincter  of,  272. 

rupture  of,  210. 

tumors  of,  235. 
Blind  external  fistula,  297. 
Blind  internal  fistula,  297. 
Blister,  325. 

caused  by  traumatism,  325. 

containing  blood,  325. 

on  the  foot,  471. 


Blister,  treatment  for,  325,  471. 

Blood  in  urine,  210. 

Blood,  transfusion  of,  777. 

Blood,  withdrawal  of,  for  examination, 

775. 
Blood-blisters,  325. 
Blood-clots,  crepitus  due  to,  367. 
Blood-letting,  585. 
Blunt  dissection  for  lipoma,  137. 

of  tonsil,  89. 
Boeckmann's  method  of  sterilization  of 

catgut,  690. 
Boil,  36,  126. 

after-treatment,  for,  127. 

carbolic  acid  for,  126. 

of  anus,  291. 

of  arm,  404. 

of  ear,  37. 

of  eyelid,  37. 

of  hand,  405. 

of  face,  36. 

of  neck,  126. 

of  nose,  37. 

poultice  for,  126. 

treatment  of,  36,  126. 

vaccine  treatment  of,  790. 
Bone,  exposing  of,  in  ulcer  of  leg,  529. 

necrosis  of,  from  suppuration  in  a 
tendon  sheath,  421. 

reposition  of  fractured,  368. 
Bottini's  operation,  236. 
Bougies  for  stricture  of  rectum,  306. 
Boxer's  ear,  4. 
Brain,  concussion  of,  17. 
Branchiogenic  cysts,  137. 
Breast,  abscess  of,  173. 

adenofibroma  of,  187. 

cancer  of  male,  191. 

contusion  of,  153. 

cystic  tumors  of,  182. 

drain  for  abscess  of,  173. 

early  diagnosis  of  tumors  of,  188. 

enlarged  glands  in  carcinoma  of,  189. 

excoriation  of,  172. 

hypertrophy  of,  187. 

incision  for  abscess  of,  173. 

palpation  of,  188. 

retracted  skin  in  carcinoma  of,  189. 

sarcoma  of,  190. 

simple  cyst  of,  183. 

solid  tumors  of,  187. 


INDEX 


707 


Breast,  spica  bandage  for,  630. 

treatment  for  adenofibroma  of,  188. 

tuberculosis  of,  180. 

tumors  of  male,  191. 
Breasts,  spica  bandage  of  both,  632. 
Bronchi,  foreign  body  in,  118. 
Bryant's  perpendicular,  487. 
Bubo,  treatment  of,  224. 
Bullet,  removal  of,  14. 

in  hand  or  arm,  337. 
Bunion,  482,  550. 
Burn,  edema  of  the  penis  and  scrotum 

in,  211. 
Burns,  aluminum  acetate  for,  27. 

antiseptic  dressing  for,  28. 

cicatricial  contraction  from,  29. 

exposure  of,  to  the  air,  27. 

of  back  of  leg,  513. 

of  external  genitals,  210. 

of  face,  25. 

of  first  degree,  treatment  of,  25. 

of  foot,  513. 

of  hands  and  arms,  393. 

of  head,  25. 

of  neck,  125. 

of  second  degree,  treatment  of,  26. 

of  third  degree,  treatment  of,  28. 

of  trunk,  170. 

oily  dressing  for,  26. 

picric  acid  for,  27. 

repair  after,  29. 

saline  solution  for,  27. 

skin  grafting  for,  29. 

skin-grafts  for,  393. 

sloughs  after,  28. 

splint  for,  393. 

X-ray,  30. 
Bursa,  gastrocnemio-semimembra- 
nosa,  481. 

incision  of,  479. 

of  the  lower  extremity,  476. 

under  the  tendo  Achillis,  481. 
Bursitis,  476. 

metatarsophalangeal,  482. 

of  foot,  treatment  of,  483. 

olecranon,  346. 
suppurative,  427. 

prepatellar,  acute,  476. 
chronic,  478. 
suppurative,  477. 
treatment  of,  479. 


Bursitis,  subdeltoid,  340. 

subglutcal,  480. 
Buttock,  ascending  spica  bandage  of, 
661. 

descending  spica  bandage  of,  662. 

gangrene  of,  from  salvarsan,  780. 
Buzz-saw,  injuries  to  fingers  from,  388. 

Calcareous  nodules  in  the  ear,  91. 
Calculus,  due  to  foreign  body  in  blad- 
der, 208. 
of     bladder     causing     incontinence, 

221. 
of  the  urethra,  207. 
Callus,  537. 

of  the  foot,  537. 
treatment  of,  537. 
Canal,  large  inguinal,  253. 
Cancer,  chimney  sweep's,  233. 

and  syphilis  of  the  testicle  compared, 

228. 
and  X-ray,  104. 
of  anus,  316. 

of  breast,  bleeding  from  the  nipple 
in,  189. 
early  diagnosis  of,  188. 
enlarged  glands  in,  189. 
retraction  of  nipple  in,  189. 
retraction  of  skin  in,  189. 
of  male  breast,  191. 
of  penis,  treatment  for,  234. 
of  rectum,  316. 
of  tonsil,  107. 

papilloma  of  skin  mistaken  for,  77. 
Canton  flannel,  687. 
Carbolic  acid,  gangrene  from,  395. 

use  of,  for  a  boil,  126. 
Carbuncle,  127. 
of  neck,  127. 

treatment  of,  128. 
Carcinoma,  of  anus,  317. 
of  cervix,  271. 
of  leg,  543. 

of  lower  extremity,  543. 
of  nipple,  190. 
of  penis,  233. 
of  rectum,  317. 
of  testicle,  234. 
of  trunk,  191. 
of  vulva,  271. 
Carcinomatous  ulcer,  543. 


798 


INDKX 


Care  of  anus,  290. 

of  tracheotomy  tube,  120. 
Carpus,  fracture  of,  384. 
Cartilage,  costal  dislocation  of,  169. 
Caruncle,  urethral,  270. 
Castration,  235. 

for  tuberculosis,  230. 

in  enlargement  of  prostate,  236. 
Casts  for  flatfoot,  710. 
Catgut,  690. 

chromic,  692. 

commercial,  692. 

in  envelopes,  692. 

in  sealed  glass  tubes,  692. 

sterilization  of,  by  boiling,  691. 
by  dry  heat,  690. 
by  formaldehyde,  691. 
by  iodin,  690. 
in  alcohol,  691. 
in  cumol,  691. 

ten-day,  692. 
Catheter,  as  a  drainage-tube,  695. 

in  the  bladder,  209. 

passage  of,  in  prostatic  hypertrophy, 
236. 

passing  of,  274. 
Catheterization,  222. 

for  retention  of  urine,  219. 

of  female,  273. 
Causes  of  retention  of  urine,  219. 

of  ulcer  of  leg,  521. 
Caustics,  in  epithelioma  of  face,  103. 

not  to  be  used  on  a  mole,  77.    . 
Cauterization    of    prolapsed    urethra, 
274. 

of  prostate,  236. 

of  rectum,  320. 
Cellulitis,  abscess  in,  402. 

gangrene  complicated  with,  397. 

incisions  for,  398. 

of  finger,  402. 

followed  by  gangrene,  403. 

of  external  genitals,  264. 

of  hand,  402. 

of  head,  33. 

of  lower  extremity,  515. 

of  neck,  125. 

of  trunk,  172. 

suppuration  in,  34. 

treatment  for,  34. 
Celluloid  thread,  694. 


Cervical    glands,    enlarged,    in    leuke- 
mia, 145. 
in  pseudoleukemia,  145. 
in  syphilis,  145. 
Cervical  lymphadenitis,  140. 
Pott's  disease,  133. 

treatment  for,  133. 
tuberculosis,  133. 
Cervix,  carcinoma  of,  271. 
catarrh  of,  264. 
dilatation  of,  266. 
erosion  of,  264. 
malignant  tumor  of,  treatment  for, 

271. 
polyp  of,  270. 
stenosis  of,  278. 

hard-rubber  plugs  for  the  cure  of, 
279. 
Chafing,  prevention  of,  287. 
Chancre,  duration  of,  225. 
of  finger,  436. 

of  genital  organs  of  female,  268. 
of  penis,  225. 
resection  of,  226. 
treatment  for,  225. 
Chancroid,  268,  300. 

infectiousness  of  discharge  in,  224. 
inguinal  adenitis  with,  223. 
of  penis,  222. 

spasm  of  sphincter  ani  with,  300. 
treatment  for,  224. 
Chancroids,  about  the  anus,  299. 

reinfection  of,  299. 
Cheek,  epithelioma  of,  96. 
suture  of  wound  of,  15. 
syphilis  of,  59. 
Chest,  anterior  figure  of  eight  bandage 
of,  626. 
contusions  of,  153. 
descending  spiral  bandage  of,  628. 
penetrating  wound  of,  157. 
posterior  figure  of  eight  bandage  of, 
627. 
Chest  and  arm,  Desauit's  bandage  of, 
637. 
Velpeau's  bandage  of,  637. 
Chilblains  of  hand,  394. 
Childhood,  incontinence  of,  220,  273. 

treatment  for,  221. 
Chimney-sweep's  cancer,  233. 
Chromic  catgut,  692. 


INDEX 


7111) 


Chronic,  external  hemorrhoids,  312, 

gonorrhea  in  female,  264. 

hemorrhoid,  311. 

operative  treatment  for,  314. 

inflammations  of  leg,  532. 

paronychia,  410. 

prepatellar  bursitis,  478. 

proctitis,  289. 

prolapse  of  rectum,  319. 

rhinitis,  53. 

serous  synovitis  of  knee,  484. 

suppuration  in  joints  of  foot,  532. 

ulcer  and  varicose  veins,  521. 

ulcer  of  the  leg,  519. 

urethritis,  216. 
Cicatrices  of  the  neck,  147. 
Cicatricial,  contraction  after  burns,  29. 

contractions  of  hand,  463. 
Cigarette  drains,  696. 
Circular  bandage,  of  neck,  613. 

of  toe,  678. 
Circular  gypsum  splint,  703. 
Circulation,  affected  by  plaster  splint, 
503. 

affected  by  bandage,  594. 
Circumcision,  247. 

as  a  cure  for  masturbation,  251. 

complications  following,  250. 

edema  after,  250. 

for  balanitis,  211. 

hemorrhage  after,  250. 

infection  after,  250. 

results  after,  250. 

retraction  of  skin  after,  250. 

surplus  skin  after,  251. 
Claudius's   method   of   sterilization   of 

catgut,  690. 
Clavicle,  dislocation  of,  168. 

fracture  of,  163. 

reduction  of,  by  operation,  167. 
Say  re  dressing  for,  165. 
treatment  for,  164. 
Cleansing  field  of  operation,  564. 
Cleft,  closure  of  pharyngeal,  76. 

of  the  lower  lip,  114. 
Cleft  palate,  112. 

operation  for,  112. 

rubber  plate  for,  115. 

treatment  for,  114. 
Clefts  of  ear,  1 16. 
Clitoris,  adhesions  of,  277. 


Closure  of  first  pharyngeal  cleft,  76. 
Coaptation  splints,  698. 
Cocain,  injection  of,  566. 

in  spinal  anesthesia,  dose  of,  583. 
Coccygeal  cysts  and  sinuses,  181. 
Coccygodynia,  192. 
Coccyx,  displaced,  192. 

removal  of,  193. 
Coffee,  a  cause  of  pruritus,  287. 
"Collar-button"  abscess,  405. 
Colles's  fracture,  deformity  in,  380. 

ulna  involved  in,  380. 
Comedo,  66. 
Complete  bandage  of  axilla,  623. 

of  neck,  620. 
Complete  fistula  in  ano,  298. 
Completion  of  bandage,  594. 
Complex  spica  bandage  of  great  toe, 

679. 
Complications,  following  circumcision, 
250. 
of  gonorrhea,  215. 
Compound  fracture  of  finger,  387. 
Compound  fractures  of  upper  extrem- 
ity, 386. 
Compresses  for  abscess  of  breast,  173. 
Concentric  figure  of  eight  bandage,  of 
elbow,  646. 
of  knee,  666. 
Concussion  of  brain,  17. 
Condyloma  of  vulva,  269. 
Congenital,  clefts  of  ear,  116. 
cysts  of  neck,  135. 
deformities,  of  anus,  322. 
of  ear,  116. 

of  female  genitals,  277. 
of  foot,  561. 
of  hand,  465. 
of  male  genitals,  244. 
hydrocele,  240. 
hypertrophy  of  finger,  469. 
sinus  near  ear,  76. 
stricture  of  rectum,  323. 
Conjunctivitis,  acute,  47. 
contagious,  48. 
granular,  49. 
purulent,  48. 
treatment  for,  48. 
Constipation  in  hemorrhoids,  312. 
Constipation  due  to  rectal  folds,  306. 
Contagion  of  ringworm,  58. 


800 


INDEX 


Contraction    of    finger    following    sup- 
puration in  tendon  sheath,  421. 
of  palmar  fascia,  465. 

Contractions,  cicatricial,  of  hand,  463. 
Control  of  hemorrhage,  568. 
Contusion,  of  abdomen,  154. 

of  back,  154. 

of  breast^  153. 

of  chest,  153. 

of  external  genitals,  255. 

of  hand,  324. 

of  head,  1. 

of  intestine,  156. 

of  lower  extremity,  471. 

of  neck,  117. 

of  nerve,  335. 

of  penis,  203. 

of  scalp,  1. 

of  testicle,  204. 
Cord,  hydrocele  of,  240. 
Corn,  538. 

treatment  of,  538. 
Costal  tuberculosis,  178. 
Cotton,  681. 

absorbent,  6S1. 

substitutes  for,  683. 

unbleached,  681. 
Cotton  thread,  694. 
Cotton  waste,  683. 
Cotton-collodion  dressing,  574. 
Coughing,  impulse  on,  in  hernia,  195. 
Crepitus  due  to  blood  clot,  367. 

false,  367. 

proof  of  fracture,  367. 
Crinoline  for  bandages,  688. 

in  gypsum  bandages,  702. 
Crossed  bandage  of  perineum,  663. 
Crossed  circular  bandage  of  head,  597. 
Crossed  union  of  radius  and  ulna,  379. 
Cupping,  586. 
Curettage  of  uterus,  267. 
Curette,  for  removal  of  adenoids,  89. 
Cutaneous  hematoma,  326. 
Cutaneous  hemorrhoids,  310. 
Cyst,  dental,  72. 

dermoid,  of  head,  72. 

mucous,  of  mouth,  71. 

of  Bartholin's  gland,  270. 

salivary,  72. 

sebaceous,  diagnosis  of,  67. 
of  head,  66. 


Cyfet,  sebaceous,  of  neck,  135. 

simple  parotid,  72. 

sublingual  salivary,  71. 

t  hypoglossal,  135. 
Cystic,  adenomata  of  breast,  183. 

tumors  of  breast,  182. 
of  external  genitals,  231. 
of  trunk,  181. 
Cystitis  in  gonorrhea,  215. 

tubercular,  229. 
Cystotomy,  suprapubic,  for  retention  of 

urine,  220. 
Cysts,  branchiogenic,  137. 

coccygeal,  181. 

of  infant  breast,  182. 

of  neck,  congenital,  135. 

of  testicle,  232. 

umbilical,  181. 

Dactylitis,  syphilitic,  436. 

differential  diagnosis  of,  438. 
Dawbarn's  needles,  574. 
Deforming  arthritis  of  arm,  434. 

of  neck,  134. 
Deformities,  of  anus,  318. 

of  ear,  116. 

of  face,  acquired,  108. 
congenital,  112. 

of  foot,  acquired,  543. 
congenital,  559. 

of  hand,  463. 
congenital,  467. 

of  nose,  108. 

of  rectum,  318. 
Deformity  after  fracture,  364. 

after  fracture  of  radius,  383. 

following   fracture   of  lower  end   of 
humerus,  375. 

in  Colles's  fracture,  380. 

in  old  fracture  of  radius,  384. 

skin  grafting  for  cicatricial,  463. 
Deltoid  atrophy  from  injury,  340. 
Demonstration  of  floating  patella,  490. 

of  fluid  in  knee-joint,  490. 
Dental  cyst,  72. 

Dermatitis,  distinguished  from  eczem^ 
432. 

from  poison  ivy,  30. 

from  heat  and  cold,  30. 

from  traumatism,  30. 

of  hand,  400. 


INDEX 


801 


Dermoid  cyst,  diagnosis  of,  73. 
near  nose,  74. 

of  ear,  75.  . 

of  head,  72. 
of  orbit,  74. 
of  trunk,  1S2. 
operation  for,  75. 
treatment  for,  75. 
Desault's  bandage  of  chest  and  arm, 

637. 
Descending    spica    bandage,    of    both 
groins,  661. 
of  buttock,  662. 
of  one  groin,  658. 
of  shoulder,  644. 
Descending   spiral   bandage,    of   abdo- 
men, 641. 
of  chest,  628. 
Descent  of  testicle,  253. 
Diabetes,  gangrene  in,  513. 
perforating  ulcer  in,  530. 
pruritus  due  to,  261. 
Diagnosis,  of  adenoids,  87. 
of  angioma,  80. 
of  dermoid  cyst,  73. 
of  epithelioma,  95. 
error  in,  98. 
of  tongue,  early,  103. 
of  fractures,  363. 
of  hernia,  194. 
of  rupture  of  urethra,  208. 
of  sebaceous  cyst,  67. 
of  ulcer  of  rectum  through  procto- 
scope, 302. 
of  wry-neck,  149. 
Diarrhea  in  ulcer  of  rectum,  302. 
Differential  diagnosis,  of  hydrocele,  238. 
of  the  cord,  241. 
of  sprain  of  knee-joint,  491. 
of  syphilitic  dactylitis,  438. 
Diffuse  lipoma,  139. 

of  neck,  138. 
Digital  examination  of  rectum,  280. 
Dilatation,  of  anus,  283. 
of  cervical  canal,  266. 
of  cervix  for  stenosis,  279. 
of  female  urethra,  260. 
of  rectal  stricture  by  the  fingers,  305. 
of   sphincter  ani  for  fistula,  297. 
of  a  stricture,  218. 
of  veins  of  rectum,  311. 


Dilatation,  sudden,  of  urethra,  217. 
Dilator,  rectal,  287. 
Discharge  of  blood  clot,  from  hemor- 
rhoid, 310. 

of  chancroid  infectious,  223. 
Disease,  Paget's,  190. 
Dislocation,  functions  after,  350. 

incision  for,  348. 

Kocher's    method    of    reduction    in, 
351 

of  clavicle,  169. 

of  costal  cartilage,  169. 

of  elbow,  351. 

with  fracture,  353. 

of  finger,  357. 

of  forefinger,  357. 

of  head  of  radius  downward,  354. 

of  humerus,  350. 

of  jaw,  24. 

of  neck,  125. 

spontaneously  reduced,  123. 

of  phalanx  of  thumb,  355. 

of  radius,  351. 
forward,  352. 

of  radius  and  ulna,  351. 
backward,  353. 

of  shoulder,  350. 

of  thumb,  349,  355. 

of  vertebra,  125,  170. 

of  wrist,  355. 

prognosis  after,  348. 

reduction  of,  347. 

Stimson's  method   of  reduction  of, 
351. 

treatment  for,  347. 

unreduced,  350. 
Dislocations,  of  arm  and  hand,  347. 

of  lower  extremity,  497. 
Displaced  coccyx,  192. 
Displacement  of  ankle  in  fracture,  504. 

of  meniscus  of  knee,  491. 
Dissection  of  lipoma,  79. 

of  prepatellar  bursa,  480. 
Division,  of  external  sphincter  for  fis- 
sure, 291. 
for  fistula,  298. 

of  narrow  meatus,  217. 

of  nerves,  476. 

of  radial  nerve,  329. 

of  Steno's  duct,  16. 

of  tendons,  476. 


S02 


INDEX 


Division,  of  tendons  of  wrist,  329. 

of  ulnar  nerve,  329. 

of  urethra,  217. 
Dorsal  hernia,  196. 
Dorsal  incision  for  phimosis,  240. 
Dose  of  stovain,  584. 
Double  oblique  circular  bandage  <>f  the 

head,-  597. 
Double  roller  bandage,  590. 

of  head,  603. 
Douches,  astringent,  in  leucorrhea,  265. 
Drain  for  abscess  of  breast,  173. 

handkerchief,  697. 

horsehair,  697. 
Drainage    after    extraction    of    foreign 
bodies,  338. 

for  suppuration  in  joint,  425. 

in  alveolar  abscess,  44. 

in  suppurative  wound,  572. 

of  abscess  cavity,  419,  576. 

of  antrum  of  Highmore,  54. 

of  felon,  412. 

of  frontal  sinus,  54. 

of  ischiorectal  abscess,  294. 

of  joint,  336. 

of  scalp  wound,  3. 

of  sebaceous  cyst,  70. 
Drainage  tubes,  694. 

for  empyema,  177. 

of  glass,  694. 

of  soft  rubber,  695. 
Draining  a  wound,  570. 
Drains,  694. 

cigarette,  696. 

for  wounds,  571. 

gauze,  685,  696. 

of  gutta-percha  tissue,  695. 

when  employed,  570. 
Dressing,  antiseptic,  for  burns,  28. 

cotton-collodion,  574. 

for  skin  grafts,  578. 

for  wounds,  574,  682. 

of  dry  gauze,  574. 

of  stump,  680. 

oily,  for  burns,  26. 

surgical,  681. 

wet,  575. 
Drop-finger,  360. 

operation  for,  361. 

radiograph  of,  362. 
Drugs  in  gonorrhea,  214 


I 'nun  membrane,  incision  of,  51. 
Dry-cupping.  586. 

Dry  dressing,  on  a  suppurating  wound, 
effect  of,  419. 

gauze  dressing,  574. 

tenosynovitis,  .'!  I  1. 
Dupuytren's  contraction  of  the  palmai 

fascia,    l(i.">. 
Duration  of  a  chancre,  225. 
Dysmenorrhea ,  2( '>< >. 

Ear,  boils  of,  37. 

calcareous  nodules  in,  91. 

congenital  cleft  of,  116. 

congenital  sinus  near,  7fi. 

deformities  of,  116. 
congenital,  116. 

dermoid  cyst  of,  75. 

fibrolipoma  of,  80. 

foreign  bodies  in,  10. 

frostbite  of,  30. 

hematoma  of,  4. 

incision  of  membrane  of,  51. 

inflammation  of,  51. 
Ear-wax,  extraction  of,  10. 
Early    diagnosis,    of    epithelioma    of 
tongue,  103. 

of  malignant  tumors  of  breast,  188. 
Early  operation  for  epithelioma,  97. 
Eccentric  figure  of  eight  bandage,  of 
elbow,  646. 

of  heel,  675. 

of  knee,  667. 
Ecchymosis  after  fracture,  364. 

subconjunctival,  2. 
Eczema  distinguished  from  dermatitis 
432. 

from  erysipelas,  432. 

from  urticaria,  432. 

of  external  genitals,  222. 

of  face,  57. 

of  fingers,  syphilitic,  432. 

of  hand,  431. 

of  leg,  519. 

of  penis,  223. 

of  scalp,  57. 

of  vulva,  261. 
Edema  after  circumcision,  250. 

of  leg,  how  overcome,  523. 

of  penis  and  scrotum  in  burn,  211. 
Effect  of  feces  in  rectum,  311. 


INDEX 


803. 


Effusion  into  shoulder-joint,  345. 

of  serum  into  a  joint,  339. 
Elastic  stocking  alter  ulcer  of  leg,  527. 
Elasticity  of  skin  flaps,  577. 
Elbow,     concentric     figure     of     eight 
bandage  of,  646. 

dislocations  of,  351. 

eccentric  figure  of  eight  bandage  of, 
646. 

miner's,  346. 
Elbow-joint,  resection  of,  after  fracture, 

376. 
Electrolysis  for  angioma,  81. 
Ellsberg's   method   of  sterilization  of 

catgut,  691. 
Elongation  of  tendon,  333. 

of  uvula,  110. 
Empyema,  175. 

drainage  tubes  for,  177. 

exploratory  puncture  in,  175. 

forced  expiration  after  operation  for, 
177. 

operation  for,  177. 
Endocervicitis,  264. 

gonorrheal,  265. 
Endometritis,  265. 

Enlarged    glands,    in     carcinoma     of 
breast,  189. 

glands  of  neck,  140. 
Epididymis,  tubercular  nodules  in,  229. 

in  gonorrhea,  216. 
Epiphysis,  separation  of,  370. 
Epispadias,  252. 
Epithelioma,  arsenious  acid  for,  104. 

diagnosis  of,  95. 

early  operation  for,  97. 

error  in  diagnosis  of,  98. 

lymph-glands  in,  100. 

mistaken  for  a  wart,  95. 

of  back,  190. 

of  cheek,  96. 

of  face,  92. 

removal  of,  by  caustics,  103. 

of  hand,  460. 

of  head,  92. 

of  lip,  93,  97. 

operation  for,  101. 

of  lower  lip,  removal  of,  101. 

of  nose,  95. 

of  penis,  233. 

of  scalp,  97. 


Epithelioma,  of  tongue,  98,  103. 
lymph-glands  in,  103. 
operation  for,  100. 

papillomatous  type  of,  94. 

precancerous  stage  of,  97. 

removal  of  tongue  for,  103. 

syphilis  and,  98. 

ulceration  of,  95. 

X-ray  for,  104. 
Epithelium,  growth  of,  29. 
Epulis,  90. 

spindle-cell  sarcoma  and,  90. 
Erosion  of  cervix,  264. 
Erysipelas,  distinguished  from  eczema, 
432. 

of  face,  35. 

of  hand,  400. 

treatment  for,  35. 
Erysipeloid  of  hand,  401. 
Esophagus,  foreign  body  in,  118. 

wounds  of,  119. 
Estimate  of  range  of  motion  in  an  af- 
fected joint,  441. 
Eversion  of  eyelid,  9. 

of  lids,  108, 
Evulsion  of  vas  deferens,  230. 
Examination,    knee-chest    position    in 
rectal,  282. 

lateral  recumbent  position  in  rectal, 
280. 

of  anus,  280. 

of  rectum,  280. 

of  shoulder-joint,  341. 

of  urethra  for  stricture,  217. 

squatting  position  in  rectal,  281. 

vaginal  and  rectal,  combined,  305. 

with  a  probe  for  fistula,  296. 
Examinations  in  injury  of  hip,  487. 
Excision,  of  a  carbuncle,  128. 

of  fistula  in  ano,  298. 

of  hemorrhoid,  316. 

of  scrotum  in  variococele,  244. 
Excoriation  of  breast,  172. 
Exostosis  of  jaw,  91. 
Exploratory    puncture    in    empyema3 

175. 
Exstrophy  of  bladder,  252. 
External  and  internal  causes  of  gan- 
grene, 513. 
External  hemorrhoids,  309. 
External  proctotomy,  306. 


S04 


INDEX 


External    urethrotomy    for    retention, 

220. 
Extraction,  of  decayed  tooth,  45. 

of   foreign   body   from  the   rectum, 
286. 

of  foreign  body  from  urethra,  207. 

of  phi  from  urethra,  207. 

of  ear-wax;  10. 

of  ingrowing  lashes,  51. 
Extravasation  of  urine,  210. 
Exuberant  granulations,  458. 
Eye,  figure  of  eight  bandage  of,  606. 

foreign  bodies  of,  8. 

inflammations  of,  47. 

wounds  of,  14. 
Eye-lashes,  ingrowing,  50. 

extraction  of,  5. 
Eyelid,  abscess  of,  37. 

boil  of,  37. 

eversion  of,  9. 
Eyelids  granular,  49. 

Face,  abrasions  of,  7. 

abscess  of,  38. 

acne  of,  32. 

acquired  deformities  of,  108. 

actinomycosis  of,  65. 

angioma  of,  80. 

anthrax  of,  59. 

boils  of,  36. 

burns  of,  25. 

congenital  deformities  of,  112. 

eczema  of,  57. 

epithelioma  of,  92. 

erysipelas  of,  35. 

furuncle  of,  36. 

herpes  of,  31. 

impetigo  contagiosa  of,  32. 

lipoma  of,  78. 

lupus  of,  64. 

milium  of,  66. 

mole  of,  76. 

nevus  of,  80. 

noma  of,  59. 

papilloma  of,  76. 

plastic  surgery  of,  580. 

removal  of  malignant  tumors  of,  92. 

rodent  ulcer  of,  94. 

tuberculosis  of,  63. 

ulcers  of,  59. 
False  crepitus,  367. 


False  point   of   motion,  proof  of  frac- 
ture, 366. 
Fascia,  I  hipuyl  ren's  conl  ruction  of  pal- 
mar, 465. 
Fastening  a  bandage,  594. 
Feces,  impacted  in  rectum,  286. 
Felon,  407,  411. 

drainage  of,  412. 
Female,  catheterization  of,  273. 
chancre  of  genital  organs  of,  26S. 
chronic  gonorrhea  in,  264. 
syphilis  in,  268. 

treatment  of  gonorrhea  in,  262. 
Female  genitals,  hemorrhage  from,  257. 
Female  urethra,  dilatation  of,  260. 
Femoral  hernia,  198. 
Femur,  fracture  of,  497. 
impacted,  489. 
neck  of,  unimpacted,  489. 
sarcoma  of,  492. 
Fenestra  in  a  plaster  splint,  707. 
Fibrolipoma,  of  ear,  80. 
of  finger,  457. 
of  hand,  452. 
of  head,  79. 
of  leg,  541. 
of  wrist,  454. 
Fibrolipomata  of  back,  185. 
Fibroma,  140. 
of  finger,  452. 
of  hand,  452. 
of  leg,  541. 
of  neck,  140. 
of  skin,  76. 
of  trunk,  185. 
Fibula,  fracture  of,  502. 
Field  of  operation,  cleansing  of,  564. 
Figure    of    eight    bandage,    of   ankle, 
671. 
of  both  axillae,  618. 
of  both  eyes,  607. 
of  both  knees,  668. 
of  eye,  606. 
of  finger,  654. 
of  fingers  and  wrist,  655. 
of  foot  and  leg,  672. 
of  forearm,  648. 
of  forehead  and  chin,  612. 
of  hand,  650. 
of  head,  600. 
of  leg,  669. 


INDEX 


m 


Figure  of  eight  bandage,  of  neck  and 

axilla,  GIG. 
Figure  of  eight  turn  of  bandage,  592. 
Filigrees,  of  silver  wire,  694. 
Finger,  abscess  of,  405. 
amputation  of,  390. 
baseball,  361. 
carbolic  gangrene  of,  396. 
cellulitis  of,  402. 
chancre  of,  436. 
compound  fracture  of,  387. 
congenital  hypertrophy  of,  469. 
crushed,  387. 
different  methods  of  amputation  of, 

391. 
dislocation  of,  357. 
drop,  360. 
fibrolipoma  of,  457. 
fibroma  of,  452. 
figure  of  eight  bandage  of,  654. 
frost-bite  of,  394. 
gangrene  of,  395. 
incision  for  abscess  of,  408,  413. 
for  dislocation  of,  360. 
for  suppuration  of,  411. 
mallet,  361. 
minute  wounds  of,  331. 
osteoma  of,  456. 
posterior  dislocation  of,  358. 
pus  in,  405. 
radiograph  of  lateral  dislocation  of, 

359. 
reattachment  of  severed,  389. 
recurrent  bandage  of,  656. 
sarcoma  of,  462. 
section  of,  to  show  sites  of  abscess, 

406. 
spiral  reverse  bandage  of,  653. 
sprain  of,  339. 
supernumerary,  468. 
suppuration  in  joint  of,  422. 
syphilitic  eczema  of,  432. 
tin  splint  for  suppuration  in  a  joint 

of,  425. 
treatment  for  dislocation  of,  359. 

for  gangrene  of,  397. 
web,  467. 
Fingers,  action  of  flexors  of,  329. 

injured  by  a  buzzsaw,  388. 
Fingers  and  wrist,  figure  of  eight  band- 
age of,  655. 


Fissure  of  anus,  289. 
Fissure,  division  of  external  sphinctei 
for,*  291. 

home  treatment  of,  290. 

stretching  of  sphincter  ani  for,  291 

treatment  of,  290. 
Fissures,  applications  for,  290. 
Fistula,  blind  external,  297. 

examination  with  a  probe  for,  296. 

in  ano,  295,  298. 
complete,  298. 

dilatation  of  sphincter  for,  297. 
division  of  sphincter  for,  298. 
excision  of,  298. 

hot  sitz  bath  for,  297. 
incision  of,  297. 

mammary,  173. 

of  urethra,  252. 

of  vagina,  277. 

symptoms  of,  296. 

treatment  for,  297. 
Flannel  bandage  for  ulcer  of  leg,  527. 
Flannel  bandages,  686. 

Canton,  687. 
Flatfoot,  556. 

gypsum  splints  for,  559. 

imprint  of,  557. 

of  transverse  arch,  560. 

rigidity  in,  557. 

tests  of,  557. 

treatment  for,  558. 
Fleas,  bites  of,  171. 

Flexor  tendons  of  fingers,  action  of,  329. 
Floating  cartilage,  484. 

of  knee,  485,  491. 
removal  of,  485. 
Floating  patella,  demonstration  of,  490. 
Fluctuation,  in  lymph  gland,  141. 

in  hydrocele,  237. 

in  lipoma,  78. 

in  tuberculous  joint,  442. 
Fluid  from  joint,  aspiration  of,  484. 

in  knee-joint,  removal  of,  500. 

in  prepatellar  bursitis,  491. 

in  tunica  vaginalis,  236. 
Folding  gauze  sponges,  684. 
Foot,  abscess  of,  518. 

blisters  of,  471. 

burns  of,  513. 

callus  of,  537. 

deformities  of,  acquired,  543. 


806 


INDEX 


Foot,  deformities  of,  congenital,  561. 

frost-bite  of,  511. 

ganglion  of,  540. 

hematoma  of,  472. 

injuries  of,  471. 

perforating  ulcer  of,  529. 

position  of,  during  the  application  of 
plaster,  505. 

spica  bandage  of,  677. 

tumors  of,  537. 
Foot  and  leg,  figure  of  eight  bandage 

of,  672. 
Forced  expiration  after  operation  for 

empyema,  177. 
Forearm,  abscess  in,  422. 

figure  of  eight  bandage  of,  648. 

position  of  hand  in  fracture  of,  378. 

spiral  reverse  bandage  of,  647. 
Forefinger,  dislocation  of,  357. 

radiograph  of,  357. 
Forehead,  lipoma  of,  78. 

and   chin,  figure   of    eight    bandage 
of,  612. 
Foreign  bodies,  drainage  after  extrac- 
tion of,  338. 

in  bladder,  208,  259. 

in  bronchi,  118. 

in  ear,  10. 

in  esophagus,  118. 

in  eye,  8. 

in  larynx,  117. 

in  mouth,  12. 

in  nose,  10. 

in  rectum,  286. 

in  throat,  12. 

in  urethra,  207,  258. 

in  vagina,  258. 

in  wounds  of  hand,  336. 

of  penis,  206. 
Foreign  body,  scar  mistaken  for,  336. 

of  bronchi  located  by  X-ray,  118. 

tracheotomy  for,  118. 
Foreskin,  incision  of,  246. 

reduction  of  retracted,  205. 

retracted  after  circumcision,  250. 

retraction  of,  at  birth,  245. 

sebaceous  material  beneath,  231. 

stretching  of,  245. 
Foreskin  and  penis,  adhesions  between, 

245. 
Four-tailed  bandage  of  jaw,  609. 


Fracture,  active  motions  after,  370. 
altered  percussion  in,  367. 
dislocation  and,  of  elbow,  353. 
crepitus  a  proof  of,  367. 
deformity  after,  364. 
ecchymosis  after,  364. 
immobility  in.  369. 
impacted,  of  humerus,  372. 
imperfect  reduction  after,  375. 
loss  of  function  a  sign  of,  368. 
measurements  for,  365. 
near  a  joint,  366. 

of  anatomical  neck  of  humerus,  372. 
of  ankle-joint,  correct  position  of  foot 

in,  507. 
of  astragalus,  507. 
of  carpus,  384. 
of  cervical  spine,  124. 
of  clavicle,  163. 
of  femur,  497. 
of  fibula,  502. 
of  fibula  and  tibia,  504. 
of  forearm,  position  of  hand  in,  378. 
of  frontal  bone,  18. 
of  great  trochanter,  497. 
of  head  of  radius,  377. 
of  humerus,  musculospiral  nerve  in- 
jured in,  374. 
of  hyoid,  123. 
of  inferior  maxilla,  19. 
of  jaw,  treatment  for,  20. 
of  larynx,  124. 

of  lower  end  of  humerus,  374. 
of  lower  end  of  radius,  380. 
of  lower  jaw,  splint  for,  22. 
of  malar  bone,  18. 
of  malleoli,  strap  splints  for,  506. 
of  metacarpal,  384. 
of  metatarsals,  509. 
of  nasal  bones,  18. 
of  neck,  124. 
of  neck  of  femur,  489. 
of  neck  of  radius,  376. 
of  olecranum,  376. 
of  os  calcis,  508. 
of  patella,  498. 

adhesive  plaster  for,  499. 

operation  for,  500. 

plaster  splint  for,  500. 

treatment  for,  499. 
of  penis,  205. 


INDEX 


807 


Fracture,  of  phalanges,  50!). 

of  phalanx,  385. 

of  radius,  deformity  following,  380. 
impacted,  380. 

of  ribs,  167. 

of  scapula,  167. 

of  shaft  of  humerus,  373. 

of  skull,  17. 

of  sternum,  167. 

of  superior  maxilla,  19. 

of  surgical  neck  of  humerus,  372. 

of  thyroid,  124. 

of  tibia,  delayed  union  in,  501. 

of  trachea,  124. 

of  ulna,  376. 

of  ulna  or  radius,  378. 

of  upper  end  of  humerus,  371. 

of  vertebra,  168. 

old  Colles's,  382. 

pain  in,  363. 

passive  motion  after,  370. 

restoration  of  function  after,  369. 

shortening  a  sign  of,  365. 

signs  of,  363. 

suppuration  in  a  compound,  386. 

swelling  after,  364. 

treatment  of,  368. 

X-ray  examination  of,  365. 
Fractured  jaw,  bandage  for,  21. 
Fractures,  anesthesia  in  diagnosis  of, 
368. 

compound,  of  upper  extremity,  386. 

diagnosis  of,  363. 

green-stick,  371. 

involving  ankle-joint,  504. 

of  ankle,  displacement  in,  504. 

of  humerus,  371. 

of  upper  extremity,  363. 
Frontal  bone,  fracture  of,  18. 
Frontal  sinuses,  suppuration  in,  53. 
Frost-bite,  amputation  for,  394. 

gangrene  due  to,  30. 

of  ears,  30. 

of  fingers,  394. 

of  foot,  511. 

of  hands,  394. 

of  head,  30. 

of  nose,  30. 

treatment  for,  394. 
Function,  of  dislocated  joint,  350. 

of  joint,  tested,  488. 
53 


Furuncle,  126. 
of  arm,  404. 
of  face,  36. 

Ganglion,  445. 

injection  treatment  for,  447. 
of  foot,  540. 
of  wrist,  445. 
operation  for,  446. 
origin  of,  445. 
recurrence  of,  447. 
treatment  for,  446. 
Gangrene,  complicated  with  cellulitis, 
397. 
from  external  and  internal  causes, 

513. 
from  carbolic  acid,  395. 
from  frostbite,  30. 
of  finger,  395. 

following  cellulitis,  403. 
of  toes,  513. 
Gangrenous  hemorrhoid,  314. 
Gastrocnemio-semimembranosous  bur- 
sitis, 481. 
Gauntlet  bandage,  655. 
Gauze,  absorbent,  683. 
for  bandages,  683. 
in  strips,  685. 

introduction  of,  within  the  uterus, 
258. 
Gauze  bandages,  685. 
Gauze  drains,  685,  696. 
Gauze  sponges,  683. 
Genitals,  abscess  of,  212. 
burns  of,  210. 
cellulitis,  of  264. 
contusions  of,  255. 
cystic  tumors  of,  231. 
eczema  of,  222. 
solid  tumors  of,  232. 
wounds  of,  208. 
female,  acquired  deformities  of,  272. 
congenital  deformities  of,  277. 
external  benign  tumors  of,  270. 
inflammations  of,  260. 
injuries  of,  255. 
male,  congenital  deformities  of,  244. 
inflammations  of,  210. 
injuries  of,  203. 
syphilis  of,  225. 
tumors  of,  231. 


SOS 


INDEX 


Gibson's  bandage  of  lower  jaw,  611. 
Gingivitis,  55. 

Gland,  hematoma  of  mammary,  153. 
incision  or  a  suppurating,  431. 
malignant  cervical,  1  i">. 
removal  of  a  suppurating,  431. 
thyroid,  tumors  of,  145. 
Glanders,  (i.">. 

Glands,  lymphatic,    swelling   of,    from 
decayed  teeth,  41. 
parotid,,  tumors  of,  107. 
suppurating   tuberculous,    of    neck. 
144. 
Glass  drainage  tubes,  694. 
I  diss  in  wound,  336. 
Gleet,  215. 

Glossitis,  syphilitic,  63. 
Goiter,  145. 

Gonococci,  absence  of,  in  simple  ure- 
thritis, 212. 
in  prostatic  ducts,  216. 
in  rectal  discharge,  299. 
in  specific  urethritis,  213. 
Gonorrhea,  213. 
astringents  in,  215. 
autoinfection  in,  49. 
bladder  affected  in,  215. 
complications  of,  215. 
cystitis  in,  215. 
drugs  in,  214. 
epididymitis  in,  216. 
injections  in,  214. 
irrigation  in,  213. 
irrigations  of  bladder  in,  264. 

of  rectum,  215. 
of  rectum,  298. 

treatment  for,  299. 
of  vulva,  262. 
rest  in,  214. 
treatment  for,  213. 
Gonorrheal  arthritis,  433. 

not  always  monarticular,  533. 
of  knee,  533. 
endocervicitis,  265. 
ophthalmia,  48. 
urethritis,  263. 
vaginitis,  261.' 
vulvitis,  262. 
Gout,  hot  applications  in,  435. 
in  lower  extremity,  534. 
of  hand,  435. 


Gouty  deposit,  removal  of,  435. 
Gradual  dilatation,  of  anus,  287. 
of  stricture  of  rectum,  306. 
Granular  conjunctivitis,  49. 
Granular  lids,  49. 
Granulations,  exuberant,  458. 
Granuloma,  458. 
of  hand,  458. 
of  umbilicus,  183. 
Great  trochanter,  relation  of,  to  ilium, 

488. 
Green-stick  fracture,  371. 
Groin,  ascending  spica  bandage  of,  657. 

descending  spica  bandage  of,  658. 
Groins,    ascending    spica    bandage    of 
both,  659. 
descending  spica  bandage  of  both, 
661. 
Growth  of  epithelium,  29. 
in  ulcer  of  leg,  524. 
of  lipoma,  79. 
Gumma,  of  hand,  436. 
of  rectum,  301. 
of  scalp,  63. 
of  testicle,  227. 
Gums,  cure  of  scrofulous,  106. 
Gunshot  wound  of  back,  156. 
Gutta-percha  drains,  695. 

tissue,  689. 
Gypsum,  use  of,  700. 
Gypsum  bandage,  application  of,  703. 

making  dart  in,  704. 
Gypsum  bandages,  700. 
wire  cloth  in,  709. 
Gypsum  splint,  reenforcing  of,  709. 
of  trunk,  712. 
removal  of,  706. 
Gypsum  splints,  for  flatfoot,  559. 
molded,  707. 

Hallux  rigidus,  554. 
valgus,  550. 

operation  for,  552. 
splint  for,  553. 
suppuration  of  joint  in,  554. 
treatment  for,  551. 
Hammer-toe,  554. 

adhesive  strips  for,  555. 
amputation  for,  556. 
incision  for,  555. 
Hand,  acquired  deformities  of,  463. 


INDEX 


809 


Hand,  aneurism  of,  448. 
boil  of  405. 
burns  of,  393. 
chilblains  of,  394. 
cellulitis  of,  402. 

cicatricial  contractions  of,  463. 

congenital  deformities  of,  467. 

contusions  of,  324. 

dermatitis  of,  400. 

eczema  of,  431. 

epithelioma  of,  460. 

erysipelas  of,  400. 

erysipeloid  of,  401. 

fibrolipoma  of,  452. 

fibroma  of,  452. 

figure  of  eight  bandage  of,  650. 

foreign  bodies  in  wounds  of,  336. 

frost-bite  of,  394. 

gout  of,  435. 

granuloma  of,  458. 

gumma  of,  436. 

inflammation  of,  399. 

metastatic  carcinoma  of,  460. 

needle  in,  336. 

nevus  of,  449. 

or  arm,  bullet  in,  337. 

papilloma  of,  455. 

punctured  wounds  of,  328. 

removal  of  foreign  bodies  from,  337. 

rice  bodies  of,  439. 

sarcoma  of,  462. 

spiral  reverse  bandage  of,  651. 

suppuration  in,  412. 

suppurative  arthritis  of,  423. 

suppurative  synovitis  of,  423. 

syphilis  of,  435. 

too  many  accessory  tendons  of,  469. 

traumatic  ulcers  of,  331. 

tumors  of,  445. 

varix  of,  449. 

warts  of,  458. 

wet  dressing  for  wounds  of,  330. 
Handkerchief  drain,  697. 
Hands  of  operator,  how  treated,  565. 
Hang-nail,  infection  through,  407. 

suppuration  in,  410. 
Harelip,  112. 

operation  for,  113. 
Head,  acute  inflammations  of,  31. 

bandages  of,  595. 

benign  solid  tumors  of,  76. 


Head,  burns  of,  25. 

cellulitis  of,  33. 

chronic  inflammations  of,  59. 

contusions  of,  1. 

crossed  circular  bandage  of,  597. 

cystic  tumors  of,  66. 

dermoid  cyst  of,  72. 

double  oblique  circular  bandage  of, 
597. 

double  roller  bandage  of,  603. 

epithelioma  of,  92. 

fibrolipoma  of,  79. 

figure  of  eight  bandage  of,  600. 

frostbite  of,  30. 

inflammations  of,  25. 

injuries  of,  1. 

knotted  bandage  of,  599. 

malignant  tumors  of,  92. 

oblique  circular  bandage  of,  596. 

occipitofrontal  bandage  of,  595. 

papilloma  of,  76. 

position  of,  in  wryneck,  149. 

recurrent  bandage  of,  601. 

partial  recurrent  bandage  of,  605. 

sarcoma  of,  104. 

sebaceous  cyst  of,  66. 

single  roller  bandage  of,  601. 

syphilis  of,  59. 

tumors  of,  66. 

wounds  of,  13. 
Head  and  neck,  anterior  figure  of  eight 
bandage  of,  615. 
posterior  figure  of  eight   bandage 
of,  613. 
Heel,  eccentric  figure  of  eight  bandage 
of,  675. 

modified  figure  of  eight  bandage  of, 
677. 

painful,  561. 
Hematocele,  204. 
Hematoma,  2. 

beneath  nail,  325. 

of  arm,  325. 

of  ear,  4. 

of  foot,  472. 

of  head,  2. 

of  mammary  gland,  153. 

of  new-born,  4. 

of  penis,  204. 

of  scalp,  3,  17. 

of  scrotum,  204. 


S10 


INDEX 


Hematoma,  of  skin,  326. 

of  vagina,  255. 

under  toe  nail,  472. 
Hemorrhage,  control  of,  56S. 

following  circumcision,  250. 

from  anus,  2S4. 

from  female  genitals,  257. 

from  nipple,  1S9. 

from  nose,  5. 

from  rectum,  284,  313. 
after  operation,  285. 
treatment  for,  2S5. 

from  umbilicus,  156. 

hemorrhoids  a  cause  of,  2S5. 

internal  symptoms  of,  155. 

in  the  orbit,  17. 

into  penis,  205. 

suprarenal  extract  to  control,  258. 
Hemorrhoids,  308. 

a  cause  of  hemorrhage,  285. 

acute,  treatment  for,  310. 

acute  external,  309. 

chronic,  310. 

chronic  external,  312. 

chronic  symptoms  of,  312. 

constipation  in,  312. 

cutaneous,  310. 

discharge  of  blood  clot  from,  310. 

excision  of,  316. 

gangrenous,  314. 

internal,  311. 

local  treatment  for,  313. 

ligation  of,  315. 

non-operative  treatment  for,  313. 

postoperative  treatment  for,  316. 

pruritus  due  to,  287. 

reduction  of,  311. 

rupture  of,  310. 

strangulation  of,  311. 
Hernia,  194. 

at  birth,  194. 

diagnosis  of,  194. 

dorsal,  196. 

femoral,  198. 

inguinal,  197. 

operation  for,  197. 

impulse  on  coughing  in,  195. 

operation  for,  195. 

rectal,  321. 

strangulated,  198. 

truss  for,  198. 


Hernia,  umbilical,  196. 

undescended  testicle  and,  2b±. 
Herpes  in  acute  rhinitis,  53. 
of  face,  31. 
of  penis,  211. 
zoster,  172. 
Hip,  treatment  for  sprain  of,  489. 

tuberculosis  of,  535. 
Hip-joint,  sprains  of,  486. 
Hooks  in  place  of  skin-sutures,  574. 
Hordeolum,  37. 
Horsehair,  693. 
drain,  697. 

for  suture  of  skin,  57:'>. 
Hot  applications  in  gout,  434. 
Hot  fomentations  for  sprain  of  ankle. 

495. 
Hot  wet  dressing,  127. 
Houston's  valves,  306. 
Humerus,  deformity  following  fracture 
of  lower  end  of,  375. 
dislocation  of,  350. 
fractures  of,  371. 
impacted,  of,  372. 
injury  of  musculospiral  nerve  in, 

374. 
non-union  after,  373. 
of  anatomical  neck  of,  372. 
of  lower  end  of,  374. 
of  shaft  of,  373. 
of  surgical  neck  of,  372. 
of  upper  end  of,  371. 
shoulder  cap  for,  372. 
Stimson's   method   of  reducing  dis- 
located, 351. 
Hydrocele,  236. 

aspiration  and  injection  for,  239. 

congenital,  240. 

differential  diagnosis  of,  238. 

fluctuation  in,  237. 

light  test  for,  238. 

of  the  cord,  240. 

differential  diagnosis  of,  241. 
position  of  testicle  in,  238. 
radical  treatment  for,  240. 
recurrence  of,  240. 
treatment  for,  simplest,  238. 
unusual  types  of,  240. 
Hymen,  imperforate,  278. 

rupture  of,  255. 
Hyoid,  fracture  of,  123. 


INDEX 


81] 


Hyoid,  suture  of,  123. 
Hypertrophic  acne  of  nose,  83. 
Hypsrtrophy,  of  breast,  187. 

of  finger,  469. 

of  inferior  turbinate,  53. 

of  lingual  tonsils,  87. 

of  prostate,  235. 

of  toe,  561. 

of  tonsil,  86. 

of  tonsil  and  malignant  growths,  107. 
Hypospadias,  252. 

Ice-bag  for  sprain  of  ankle,  495. 
Immobility  after  fracture,  369. 
Impacted  feces  in  rectum,  286. 
Impacted  fracture  of  femur,  489. 

of  radius,  380. 
Imperfect  reduction  after  fracture,  375. 
Imperforate  anus,  322. 
Imperforate  hymen,  278. 
Impetigo  contagiosa  of  face,  32. 
Imprint  of  flatfoot,  557. 
Impulse  of  coughing,  in  hernia,  195. 

in  varicocele,  243. 
Incised  wound  of  joint,  335. 
Incision  and  suture  for  web-finger,  467. 
Incision,  for  abscess  in  little  finger,  417. 

for  abscess,  of  thumb,  417. 
of  finger,  408,  413. 

for  alveolar  abscess,  46. 

for  cellulitis,  398. 

for  dislocation,  348. 
of  finger,  360. 

for  fistula  in  ano,  297. 

for  hammer  toe,  555. 

for  hematoma  beneath  nail,  326. 

for  phimosis,  248. 

for  removal  of  floating  cartilage,  486. 

for  suppurating  glands  of  axilla,  430. 

for  suppuration  of  finger,  411. 

in  wrist  for  abscess,  417. 

of  bursa,  479. 

of  foreskin,  246. 

of  membrane  of  ear,  51. 

of  pharynx  for  abscess,  56. 

of  scalp,  3. 

of  suppurating  gland,  431. 

to  open  knee-joint,  486. 
Inclusion  cyst  of  palm,  450. 
Incontinence,  of  childhood,  220,  273. 

of  anus  following  operation,  321. 


Incontinence,  of  anus,  operation    for, 
321. 
purse-string  suture  for,  322. 

of  old  age,  221. 

of  sphincter  ani,  321. 

of  urine,  220,  272. 

vesical  calculus  a  cause  of,  221. 
Infants,  treatment  for  prolapse  of  rec- 
tum in,  318. 
Infancy,  retention  cysts  of,  182. 
Infected  insect  bites,  518. 
Infection,  following  circumcision,  250. 

following  paracentesis,  201. 

in  wound  of  joint,  475. 

in  wounds,  399. 

mixed,  226. 

of  cervical  gland,  141. 

through  an  insect  bite,  171. 

through  hang-nail,  407. 

toothache  a  sign  of,  45. 
Infectiousness   of   discharge    in   chan- 
croid, 224. 
Inferior  maxilla,  fracture  of,  19. 
Inferior  maxillary  nerve,  injected  with 

alcohol,  783. 
Inferior    turbinate,     hypertrophy    of, 

53. 
Inflammation,  acute,  31. 
in  ulcer  of  leg,  523. 

of  anus,  286. 

of  Bartholin's  gland,  263. 

of  ear,  51. 

of  eye,  47. 

of  female  genitals,  260. 

of  hand,  399. 

of  head,  25. 
chronic,  59. 

of  leg,  532. 

of  male  genitals,  210. 

of  mouth,  55. 

of  nose,  53. 

of  penis,  210. 

of  rectum,  288. 

of  sebaceous  cyst,  68. 

of  skin,  57. 

of  throat,  55. 

of  urethra,  213. 

types  of  local,  399. 
Infusion,  585. 
Ingrowing  lashes,  50. 
Ingrown  nail,  544. 


S12 


INDEX 


Ingrown  nail,  operation  for,  547. 
result  after,  548. 
treatment  for,  546. 
Inguinal  adenitis  with  chancroid,  223. 
Inguinal  canal,  large,  253. 
Inguinal  glands,  infected,  removal  of, 

224. 
Inguinal  hernia,  197. 
Injection  of  median  cephalic  vein,  584. 
of  alcohol  for  neuralgia,  782. 
of  hot  water  for  angioma,  81. 
of  cocain,  566. 
of  saline  solution,  585. 
of  salvarsan,  780. 
Injection  treatment  of  a  ganglion,  447. 

of  neuralgia,  782. 
Injections  in  gonorrhea,  214. 
Injuries  and  inflammations,   of  neck, 

117. 
Injuries,  of  anus,  280. 
of  arm,  324. 

of  cord  in  fracture  of  neck,  124. 
of  female  genito-urinary  organs,  255. 
of  foot,  471. 
of  head,  1. 
of  leg,  471. 

of  lower  extremity,  471. 
of  male  genito-urinary  organs,  203. 
of  rectum,  280. 
of  testicle,  203. 
of  trunk,  153. 
of  upper  extremity,  324. 
to  fingers  from  buzz-saw,  388. 
Injury,  abdominal  rigidity  after,  155. 
by  a  mangle,  393. 
of  hip,  examinations  in,  487. 
of  musculospiral  nerve  in  fracture  of 

humerus,  374. 
of  periosteum  of  a  rib,  167. 
of  spine,  tests  for,  161 . 
treatment  for,  162. 
producing  atrophy  of  the  deltoid,  342. 
Insect     bites,     infection     caused     by 
scratching  of,  171. 
infected,  518. 
Inspection  of  anus,  280. 

of  rectum  through  speculum,  283. 
Insertion  of  needle  for  lumbar  punc- 
ture, 581. 
of  tracheotomy  tube,  119. 
Instruments  for  minor  operations,  565. 


Instruments,  for  removal  of  adenoids, 
90. 

for  removal  of  tonsil,  88. 

for  tracheotomy,  120. 
Interdental  splint,  22. 
Intermuscular  lipoma,  140. 
Internal  hemorrhage,  symptoms  of,  155. 
Internal  hemorrhoids,  311. 
Internal  proctotomy,  306. 
Internal  urethrotomy,  218. 
Interrupted  suture,  572. 
Intertrigo,  286. 
Intestinal   obstruction   in   stricture   of 

rectum,  304. 
Intestine,  contusion  of,  156. 

slough  of,  following  contusion,  156. 
Intubation,  122. 

tube,  withdrawal  of,  122. 
Iodoform  poisoning,  31. 
Irrigation,  in  gonorrhea,  213. 

of  abscess,  576. 

of  bladder  in  chronic  gonorrhea,  264. 

of  joint,  335,  484. 

of  rectum,  continuous,  289. 
in  gonorrhea,  215. 
Ischiorectal  abscess,  291. 

tuberculous,  295. 
Itching  about  anus,  287. 

and  eczema  in  ulcer  of  leg,  524. 

of  the  vulva,  260. 
Itching  piles,  313. 

Jacket  of  plaster  of  Paris,  687. 
Jaw,  angiosarcoma  of,  106. 

Barton's  bandage  of,  609. 

complications  of  fractures  of,  23. 

dislocation  of,  24. 

exostosis  of,  91. 

four-tailed  bandage  of,  609. 

Gibson's  bandage  of,  611. 

necrosis  of,  42. 

non-union  after  fracture  of,  23. 

osteoma  of,  91. 

sequestrum  of,  43. 

subluxation  of,  24. 

treatment  for  fracture  of,  20. 
Joint,  dislocated,  function  of,  350. 

drain  of,  336. 

drainage  for  suppuration  in,  425. 

effusion  of  serum  into,  339. 

estimate  of  range  of  a  motion  in,  441. 


INDEX 


813 


Joint,  fluctuation  in  tuberculous,  442. 

fracture  near,  366. 

incised  wound  of,  335. 

infection  in  wound  of,  475. 

irrigation  of,  335,  484. 

punctured  wound  of,  475. 
Joints,  local  heat  in  tuberculosis  of,  441. 

of  foot,  chronic  suppuration  in,  532. 

wounds  of,  335. 

Kangaroo  tendon,  692. 
Keloid,  184. 

of  trunk,  184. 

treatment  of,  184. 
Knee,  concentric  figure  of  eight  band- 
age of,  666. 

eccentric  figure  of  eight  bandage  of, 
667. 

floating  cartilage  of,  491. 

gonorrheal  arthritis  of,  533. 

rupture  of  ligament  of,  496. 

sarcoma  of,  542. 

sprain  of,  489. 
Knee-chest  position  in  rectal  examina- 
tion, 282. 
Knee-joint,  acute  suppuration  in,  491. 

demonstration  of  fluid  in,  491. 

floating  cartilage  in,  485. 

incision  to  open,  486. 

removal  of  fluid  from,  500. 

suppurative  synovitis  of,  532. 

wound  of,  475. 
Knees,  figure  of  eight  bandage  of  both, 

668. 
Knot,  tying  of,  under  tension,  573. 
Knotted  bandage  of  head,  599. 
Kocher's  method  of  reduction  in  dis- 
location, 351. 

Laceration  of  the  perineum,  acute,  256. 
of  long  duration,  275. 
treatment  for,  256. 
Lamb's  wool,  683. 
Larynx,  foreign  body  in,  117. 

fracture  of,  124. 
Lateral  incisions  for  phimosis,  247. 
Lateral  ligament  of  knee,  rupture  of, 

496. 
Lateral   recumbent   position  in   rectal 

examination,  280. 
Leeching,  587. 


Leg,  abscess  in,  517. 

aneurism  of,  540. 

burns  of,  513. 

carcinoma  of,  543. 

chronic  inflammations  of,  532. 

eczema  of,  519. 

fibrolipoma  of,  541. 

fibroma  of,  541. 

figure  of  eight  bandage  of,  (Hi!). 

injuries  of,  471. 

lipoma  of,  541. 

lymphadenitis  of,  517. 

lymphangitis  of,  515. 

phlebitis  of,  515. 

rupture  of  vein  of,  474. 

sarcoma  of,  542. 

sebaceous  cyst  of,  540. 

serous  synovitis  of,  483. 

spiral  reverse  bandage  of,  670. 

subperiosteal  hematoma  of,  473. 

thrombosis  of,  515. 

tumors  of,  537. 

ulcer  of,  519. 
Lesions  of  syphilis  in  lower  extremity, 

534. 
Leucoplakia,  103. 

of  tongue,  98. 
Leucorrhea,  265. 
Leukemia,  cervical  glands  enlarged  in, 

145. 
Lids,  eversion  of,  108. 
Ligament  of  knee,  rupture  of,  491. 
Ligation,  of  dilated  veins  in  varicocele, 
244. 

of  hemorrhoids,  315. 

of  varicose  veins,  539. 

of  vein,  474. 

of  vessels,  332. 
Ligatures,  689. 

tying  of,  568. 
Light  test  for  hydrocele,  238. 
Limbs,  measurements  of,  487. 
Linen  thread,  694. 
Lip,  abscess  of,  38. 

epithelioma  of,  93,  97. 
removal  of,  101. 

sunburn  of,  29. 

syphilis  of,  59. 
Lipoma,  137. 

blunt  dissection  for,  137. 

diffuse,  139. 


814 


i.\Di:.\ 


Lipoma,  dissection  of,  79. 
fluctuation  iu,  78. 
growth  of,  79. 
intermuscular,  140. 
of  arm,  451. 
of  face,  78. 
of  forehead,  78. 
of  leg,  544. 
of  neck, 137. 
of  trunk,  185. 
Lipoma,  simple,  137. 
treatment  of,  137. 
Lips,  thick,  115. 
Local  anesthesia,  566.' 
Local  anesthetic  for  tonsillectomy,  89. 
Local  heat  in  tuberculosis  of  joints,  441. 
Local  treatment  for  internal   hemor- 
rhoids, 313. 
for  rheumatism,  433. 
Loss  of  function,  a  sign  of  fracture,  368. 

in  tuberculous  joint,  442. 
Lower  extremity,  acute  rheumatism  of, 
533. 
amputation  of,  509. 
bandages  of,  657. 
bursae  of,  476. 
carcinoma  of,  543. 
cellulitis  of,  515. 
contusions  of,  471. 
dislocations  of,  497. 
gout  in,  534. 
injury  of,  471. 
lesions  of  syphilis  in,  534. 
lymphangitis  of,  515. 
sarcoma  of,  542. 
sprains  of,  486. 
suppurative  synovitis  of,  532. 
tuberculosis  of,  535. 
wounds  of,  475. 
Lower  jaw,  complications  of  fracture 

of  the,  23. 
Lower  lip,  cleft  of,  114. 
Ludovici,  angina,  131. 
Lumbago,  158. 
Lumbar  puncture,  581. 

insertion  of  needle  for,  581. 
Lumbar  spine,  section  of,  581. 
transverse  section  of,  582. 
"Lumpy  jaw,"  65. 
Lupus  of  back,  178. 
of  face,  64. 


Lymphadenitis,  acute,  140. 

cervical,  140. 

of  arm,  429. 

of  axilla,  429. 

of  leg,  517. 

treatment  for  chronic,  142. 
Lymphangitis,  of  arm,  428. 

of  leg,  515. 

of  lower  extremity,  515. 
Lymph  glands,  fluctuation  in,  141. 

in  epithelioma,  100. 
of  tongue,  103. 

infection  of  cervical,  141. 

submaxillary    gland    mistaken    for, 
142. 

Making  a  dart  in  a  gypsum  bandage, 

704. 
Malar  bone,  fracture  of,  18. 
Malignant  cervical  glands,  145. 
Malignant  growth,  in  mole,  92. 

in  wart,  92. 
Malignant  tumor,  of  cervix,  treatment 
of,  271. 
of  tonsil,  107. 
Malignant  tumors,  of  face,  removal  of, 
92. 
of  head,  92. 
of  rectum,  316. 
Mallet-finger,  361. 
Mammary  abscess,  173. 
fistula,  173. 

gland,  hematoma  of,  153. 
tuberculosis  of,  180. 
Mandible.     See  Jaw. 
necrosis  of,  42. 
sequestrum  of,  43. 
Mangle  injury,  393. 
Manipulation  for  wryneck,  151. 
Many-tailed  bandage  of  abdomen,  642. 
Marginal  abscess  of  anus,  291. 
Massage,  toughening  of  nipples  by,  174. 
Massage  of  prostate  gland,  217. 
Masturbation,  circumcision  as  a  cure 

for,  251. 
Materials  for  a  roller  bandage,  589. 
Matrix  of  nail  not  removed  by  opera- 
tion, 549. 
Mattress  stitch  of  tendon,  333. 
Measurements  for  fracture,  365. 
of  two  limbs,  487. 


iM)i:.\ 


81.1 


Measures,  to  cleanse  ulcer  of  leg,  523. 

to  overcome  chronic  edema  of  leg, 
523. 

to  stimulate  granulation  in  ulcer  of 
leg,  523. 
Meatus,  narrow,  251. 
division  of,  217. 
Median   cephalic   vein,  injection  into, 

584. 
Melanosarcoma  of  abdomen,  191. 
Membrane  of  ear,  incision  of,  51. 
Meningitis  after  wound  of  periosteum, 

17. 
Meniscus  of  knee,  displacement  of,  491. 
Menstruation,  painful,  266. 
Metacarpal,  fracture  of,  384. 
Metastatic  carcinoma  of  hand,  460. 
Metatarsalgia,  560. 
Metatarsals,  fracture  of,  509. 
Metatarsophalangeal  bursitis,  482. 
Metal  drainage  tubes,  694. 
Metal  splints,  698. 

Method,  of  holding  foot  during  applica- 
tion of  plaster,  505. 

of  holding  trocar  and  cannula,  200. 

of  lengthening  a  tendon,  464. 

of  tying  ligatures.  569. 
Micro-organism  of  syphilis,  225. 
Mikulicz  method  of  drainage,  697. 
Milium  of  face,  66. 
Miner's  elbow,  346. 

Minor  operations,  instruments  for,  565. 
Minor  surgery,  results  in,  563. 
Minor  surgical  technique,  563. 
Minute  wounds  of  fingers,  331. 
Mixed  infection,  226. 
Modified  eccentric  figure  of  eight  band- 
age of  the  heel,  677. 
Molded  gypsum  splints,  707. 

for  fracture  of  radius,  382. 
Molded  plaster  splint,  707. 
Mole,  caustics  not  to  be  used  on,  77. 

malignant  growth  in,  92. 

of  face,  76. 

removal  of,  78. 

sarcomatous  growth  of,  77. 
Monochloracetic  acid  for  warts  of  anus, 

308. 
Mortality  after  fracture  of  the  thyroid, 

124. 
Morton's  disease,  560. 


Motion,  false  point  of,  a  proof  of  frac- 
ture, 366. 

test  for  a  false  point  of,  366. 
Motoring,  a  cause  of  neuritis,  342. 
Mouth,  epulis  of,  90. 

foreign  bodies  in,  12. 

inflammations  of,  55. 

mucous  cyst  of,  71. 

patches  in,  62. 

tuberculosis  of,  64. 

wounds  of,  15. 
Mucous  cyst  of  mouth,  71. 
Mucous  patches,  about  anus,  300. 
in  the  mouth,  62. 
on  the  penis  and  scrotum,  226. 
Multiple  lipomata  of  arm,  452. 
Muscle,  rupture  of  biceps,  327. 
Muscular  spasm  in  tuberculosis,  489. 
Musculospiral  nerve  injured  in  fracture 

of  humerus,  374. 
Muslin,  oiled,  689. 

unbleached,  686. 

use  of,  for  bandages,  686. 
Myositis,  wryneck  from,  148. 

Nail,  hematoma  beneath,  325. 

rate  of  growth  of,  410. 

removal  of,  in  paronychia,  410. 
Nares,  plugging  the  posterior,  6. 
Narrow  meatus,  251. 
Nasal  bones,  fracture  of,  18. 

deformities,  108. 

septum,  deviated,  109. 

submucous  excision  of,  109. 

splint,  19. 

spur,  92. 
Neck,  abscesses  of,  130. 

acquired  deformities  of,  147. 

anthrax  of,  132. 

arthritis  of,  134. 

boil  of,  126. 

burns  of,  125. 

carbuncle  of,  127. 

cellulitis  of,  125. 

cicatrices  of,  147. 

circular  bandage  of,  613. 

complete  bandage  of,  620. 

congenital  cysts  of,  135. 

contusions  of,  117. 

deep  abscess  of,  131. 

deep  suppuration  of,  130. 


816 


INDEX 


Neck,  dislocation  of,  125. 

spontaneously  reduced,  123. 
diffuse  lipoma  of,  138. 
enlarged  glands  of,  I  K). 

fibroma  of,  1  10. 

fracture  of,  124. 

injuries  and  inflammations  of,  117. 

injury  of  cord  in  fracture  of,  124. 

lipoma  of,  137. 

removal  of  enlarged  glands  from,  142. 

sebaceous  cyst  of,  135. 

sprain  of,  122. 
shock  in,  123. 

treatment  for  carbuncle  of,  127. 

tuberculosis  of,  133. 

tuberculous  glands  of,  142. 

tumors  of,  135. 

wounds  of,  118. 
Neck  and  axilla,  bandages  of,  613. 

figure  of  eight  bandage  of,  616. 

oblique  circular  bandage  of,  619. 
Neck    and    chest,    anterior    figure    of 

eight  bandage  of,  625. 
Neck   of  femur,   unimpacted   fracture 

of,  489. 
Necrosis  of  bone  from  pus  in  a  tendon 
sheath,  421. 

of  mandible,  42. 
Necrotic  bone,  probing  for,  43. 
Needle  in  hand,  336. 
Needles,  straight  and  curved,  for  skin, 

573. 
Nerve,  contusion  of,  335. 

division  of  ulnar,  329. 

injection  of  alcohol  into,  782. 

restoration  of   function  in  divided, 
335. 

suture  of,  334. 
Nerves,  division  of,  476. 
Neuralgia  of  testicle,  206. 
Neuritis,  of  arm,  342. 

of  shoulder,  342. 
Neurofibroma  of  arm,  455. 
Nevus  of  face,  80. 

of  hand,  449. 
New-born,  hematoma  in  the,  4. 
Nipple,  hemorrhage  of,  189. 

retraction  of,  in  cancer  of  breast,  189. 
Nipples,  toughening  of,  by  massage,  174. 

treatment  for  retracted,  174. 
Noma,  59. 


Nbn-absorbable  sutures,  693. 
Non-operative    treatment    for    hemor- 
rhoids, 313. 
for  stricture  of  rectum,  305. 
Non-union,  alter  fracture  of  humerus, 
373. 

in  fracture  of  lower  jaw,  23. 

in  fracture  of  radius,  379. 

in  fracture  of  the  tibia,  501. 
Nose,  boils  of,  37. 

deformities  of,  108. 

dermoid  cyst  near,  74. 

deviation  of  septum  of,  109. 

epithelioma  of,  95. 

foreign  bodies  in,  10. 

frostbite  of,  30. 

hemorrhage  from,  5. 

inflammations  of,  53. 

overgrowth  of,  83. 

rosacea  hypertrophica  of,  83. 

spur  of,  92. 

submucous  excision  of  septum  of,  109. 

support  for  sunken,  108. 

Oakum,  683. 

Oblique  circular  bandage  of  head,  596. 

of  neck  and  axilla,  619. 
Obstruction  of  tear-duct,  108. 
Occipitofrontal  bandage  of  head,  595. 
Oiled  muslin,  689. 
Oiled  paper,  689. 
Oiled  silk,  689. 
Oily  dressing  for  burns,  26. 
Old*  age,  incontinence  of,  221. 
Old  Colles's  fracture,  383. 
Old  fracture  of  radius  with  deformity, 

384. 
Olecranon  bursitis,  346. 
suppurative,  427. 

fracture  of,  376. 
Opening  an  abscess,  575. 
Operating-room,  563. 
Operation,  Bottini's,  236. 

for  acne  hypertrophica,  85. 

for  adenoids,  89. 

for  chronic  hemorrhoids,  314. 

for  cleft  palate,  112. 

for  dermoid  cyst,  75. 

for  dislocation  of  thumb,  357. 

for  drop  finger,  361. 

for  empyema,  177. 


INDEX 


817 


Operation,  for  epithelioma,  100. 

for  fracture  of  patella,  500. 

for  ganglion  of  wrist,  446. 

for  hallux  valgus,  552. 

for  harelip,  113. 

for  hernia,  195. 

for  incontinence  of  anus,  321. 

for  ingrown  nail,  547. 

for  inguinal  hernia,  197. 

for  ischiorectal  abscess,  294. 

for  phimosis,  246. 

for  phimosis  in  infancy,  247. 

for  prolapse  of  urethra,  275. 

for  prolapse  of  uterus,  277. 

for  rectal  stricture,  305. 

for  sebaceous  cyst,  69. 

for  ulcer  of  leg,  528. 

for  wryneck,  151. 

incontinence  of  anus  following,  321. 

plastic,  580. 

preparation  of  patient  for,  564. 

solution  for,  565. 
Operative  technique,  563. 
Operator's  hands,  how  treated,  565. 
Ophthalmia,  gonorrheal,  48. 
Orbit,  dermoid  cyst  of,  74. 

hemorrhage  in,  17. 
Orchitis,  syphilitic,  226. 
Organ,  rupture  of  intraabdominal   155. 
Origin  of  a  ganglion,  445. 
Os  calcis,  fracture  of,  508. 
Osteitis  deformans,  434. 
Osteoma,  of  finger,  456. 

of  great  toe,  541. 

of  jaw,  91. 

of  tibia,  541. 
Osteomyelitis  of  arm,  443. 
Otoliths,  91. 

Overextension  of  thumb,  357. 
Overgrowth  of  nose,  83. 
Overlapping  of  turns  of  a  bandage,  591. 

Paget's  disease,  190. 
Pain  in  fracture,  363. 

in  tuberculous  joint,  442. 
Painful  heel,  561. 
Palm,  inclusion  cyst  of,  450. 

suppuration  in,  414. 

swelling  in  abscess  of,  413. 
Palpation,  of  axilla,  189. 

of  breast,  188. 


Palpation,  of  rectum,  281. 

in  squatting  position,  305. 
Paper,  oiled,  689. 
Papilloma,  of  face;,  76. 

of  hand,  455. 

of  head,  76. 

of  lip  mistaken  for  syphilis,  76. 

of  penis,  232. 

of  skin  mistaken  for  cancer,  77. 

of  trunk,  185. 

of  vulva,  270. 
Papillomatous  type  of  epithelioma,  94. 
Paracentesis,  199. 

infection  following,  201. 
Paraphimosis,  205. 
Parasites,  pruritus  due  to,  261. 
Paronychia,  407. 

acute,  408. 

chronic,  410. 

removal  of  old  nail  in,  410. 
Parotid  cyst,  72. 
Parotid  tumors,  106. 

and  lymphatic  glands,  107. 
Partial  recurrent  bandage  of  head,  605. 
Passage  of  steel  sound  into  urethra,  218. 

of  catheter,  274. 
Passive  motion  after  fracture,  370. 

after  a  sprain,  339. 
Patella,  fracture  of,  498. 
Patient,  preparation  of,  for  operation, 

564. 
Pediculi,  abscesses  from,  130. 

removal  of,  130. 
Pediculosis  corporis,  171. 
Pelvis,    fracture   of,    with    rupture    of 

bladder,  210. 
Penetrating  wound,  of  abdomen   158. 
of  chest,  157. 
of  pericardium,  157. 
of  pleural  cavity,  157. 
Penis,  carcinoma  of,  233. 

chancre  of,  225. 

chancroid  of,  222. 

contusion  of,  203. 

eczema  of,  223. 

edema  of,  in  burn,  211. 

epithelioma  of,  233. 

foreign  bodies  of,  206. 

"fracture  of,  205. 

hematoma  of,  204. 

hemorrhage  into,  205. 


818 


INDEX 


Penis,  herpes  of,  211. 

inflammations  of,  210. 

mucous  patches  on,  226. 

papilloma  of,  232. 

short  frenum  of,  251. 

treatment  for  cancer  of,  234. 

warts  of,  233. 
Percussion  note  altered  in  fracture,  367. 
Perforating  ulcer  of  foot,  529. 

of  toes,  531. 
Pericardium,    penetrating    wound    of, 

157. 
Perineum,  crossed  bandage  of,  663. 

laceration  of,  acute,  256. 
old,  275. 
suture  for,  256. 
treatment  for,  256. 
Periosteum,  wounds  of,  16. 

followed  by  meningitis,  17. 
Perirectal  abscess,  291. 
Peritonsillar  abscess,  55. 
Pessary  for  prolapsed  uterus,  276. 
Phalanx,  fracture  of,  385,  509. 
Pharyngeal  cleft,  closure  of  first,  76. 
Pharynx,  abscess  of,  56. 
Phimosis,  244. 

incisions  for,  248. 
dorsal,  247. 
lateral,  247. 

operation  for,  on  an  infant,  247. 

operative  treatment  for,  246. 

recurrence  of,  251. 

sutures  for,  249. 
Phlebitis,  treatment  for,  516. 
Phlebitis  of  leg,  515. 
Picric  acid  for  burns,  27. 
Piles,  itching,  313. 
Pinworms,  treatment  for,  287. 
Plantaris  muscle,  rupture  of  tendon  of, 

475. 
Plaster  casts,  710. 

application  of,  703. 
Plaster  jacket,  712. 

stockinette  for,  687. 
Plaster  of  Paris  bandages,  700. 

for  cervical  tuberculosis,  134. 
Plaster  splint,  circulation  affected  by, 
503. 

for  fracture  of  patella,  500. 

molded,  707. 

to  cut  fenestra  in,  707. 


Plastic  operations,  5S0. 

superior  to  Thiersch  grafts,  579. 
Plastic  surgery  of  face,  580. 
Plate  for  cleft  palate,  115. 
Pleural  cavity,  penetrating  wound  of, 
157. 

pus  in,  175. 
Plugs  for  stricture  of  rectum,  306. 
Poison  ivy,  dermatitis  due  to,  30. 
Poisoning  from  iodoform,  31. 
Pointed  condylomata  of  anus,  307. 
Polyp  of  anus,  308. 

of  cervix,  270. 

resection  of  mucous  membrane  for, 
271. 

of  rectum,  308. 
Popliteal  artery,  aneurism  of,  540. 
Position  of  foot   in  fracture  of  ankle- 
joint,  507. 

of  hand  in  fractures  of  forearm,  378. 

of  head  in  wryneck,  149. 

of  testicle  in  hydrocele,  238. 

of  ulnar  artery,  328. 
Posterior  dislocation  of  finger,  358. 
Posterior  figure   of   eight  bandage,  of 
chest,  627. 
of  head  and  neck,  613. 
Posterior  nares,  plugging  of,  6. 
Posterior  urethritis,  216. 
Postoperative    treatment    for    hemor- 
rhoids, 316. 
Pott's  disease,  cervical,  133. 

treatment  for,  133. 
Poultice  for  a  boil,  126. 
Powder  grains,  removal  of,  8. 
Precancerous  stage  of  epithelioma,  97. 
Predisposing  causes  of  ulcer  of  leg,  520. 
Preparation,  of  bandage,  588. 

of  gauze  sponges,  684. 

of  gypsum  bandages,  701. 

of  patient  for  operation,  564. 
for  rectal  operation,  297. 
Prepatellar  bursa,  dissection  of,  480. 
Prepatellar  bursitis,  476. 

fluid  in,  491. 
Prepuce,  serous  cyst  of,  231. 
Pressure  of  bandage,  amount  of,  593. 
Prevention  of  chafing,  287. 
Primary  lesion  of  anthrax,  132. 
Principles  of  roller  bandage,  588. 
Probing  for  necrotic  bone,  43. 


INDEX 


810 


Proctitis,  acute,  288. 
chronic,  289. 
treatment  for,  289. 
Proctoscope,  diagnosis  of  ulcer  of  rec- 
tum through,  302. 
for  inspection  of  rectum,  281. 
Proctotomy,  external,  306. 

internal,  306. 
Profundus  tendons,  test  for  division  of, 

330. 
Prolapse  of  female  urethra,  274. 

of  uterus,  275. 
Prolapsed    hemorrhoid,    reduction    of, 

313. 
Prostate,  castration  in  enlargement  of, 
236. 
cauterization  of,  236. 
massage  of,  217. 
tumors  of,  235. 
Prostatectomy,  236. 
Prostatic  ducts,  gonococci  in,  216. 
Prostatic  hypertrophy,  235. 

passage  of  catheter  in,  236. 
Proud  flesh,  458. 
Pruritus,  260. 

coffee  a  cause  of,  287. 
due  to  diabetes,  261. 
to  parasites,  261. 
to  hemorrhoids,  287. 
to  vaginal  discharge,  261. 
treatment  for,  287. 
Pruritus  ani,  287. 

Pseudoleukemia,    cervical    glands    en- 
larged in,  145. 
Punctured  wound  of  a  joint,  475. 

of  the  hand,  328. 
Punctures,  ganglion  treated  by,  448. 
Purse-string  suture  for  incontinence  of 

anus,  322. 
Purulent  conjunctivitis,  48. 
Purulent  vaginal  discharge,  258. 
Pus  in  a  blister,  325. 
in  a  tendon  sheath,  412. 
outside  a  tendon  sheath,  418. 
Pus  finger,  405. 

Radial  artery,,  division  of,  328. 
Radial  nerve,  division  of,  329. 
Radical  treatment  for  hydrocele,  240. 
Radiograph,  of  dislocation  of  forefinger, 
357. 


J{,:uliograph  of  dislocated  thumb,  349. 

of  drop-finger,  362. 

of  lateral  dislocation  of  finger,  359. 

showing  loss  of  bone  following  sup- 
purative arthritis,  424. 
Radius,  deformity  after  fracture  of,  383. 

dislocation  of,  351. 
downward,  354. 
forward,  352. 

fracture  of,  impacted,  380. 

molded  gypsum  splints  for,  383. 

fracture  of  head  of,  377. 
of  lower  end  of,  380. 
of  neck  of,  376. 

non-union  in  fracture  of,  379. 

subluxation  of,  354. 
Radius  and  ulna,  crossed  union  of,  379. 

dislocation  of,  351. 
Ragged  wounds,  treatment  for,  14. 
Railroad  spine,  161. 
Ranula,  71. 
Rape,  258. 
Rapid  dilatation  of  stricture  of  rectum, 

306. 
Rate  of  growth  of  finger  nail,  410. 
Ray  fungus  in  actinomycosis,  65. 
Reattachment  of  a  severed  finger,  389. 
Rectal  anesthesia,  764. 
Rectal  dilator,  287. 
Rectal  discharge,  gonococci  in,  299. 
Rectal  disease,  use  of  probe  in,  280. 
Rectal  hernia,  321. 

Rectal   operation,  preparation   of   pa- 
tient for,  297. 
Rectal  speculum,  282. 
Rectal  stricture  dilated  by  fingers,  305. 
Rectal  tuberculosis,  301. 
Rectum,  abscess  of,  291. 
treatment  for,  293. 

bougies  for  stricture  of,  306. 

cancer  of,  316. 

cauterization  of,  320. 

chronic  prolapse  of,  319. 

congenital  stricture  of,  323. 

continuous  irrigation  of,  289. 

deformities  of,  318. 

diarrhea  in  ulcer  of,  302. 

digital  examination  of,  280. 

dilation  of  veins  of,  311. 

effect  of  feces  in,  311. 

examination  of,  280. 


S20 


INDEX 


Rectum,  foreign  1  ><><li«^s  in.  286. 
gonorrheal  of,  298. 
gradual    dilatation    of    stricture    of, 

306. 
gumma  of,  301. 
hemorrhage  from,  284,  313. 
Houston's  folds  in.  306. 
inflammation  of,  288. 
injuries  of,  280. 
inspection  of,  through  a  proctoscope, 

281. 
intestinal  obstruction  in  stricture  of, 

304. 
irrigation  of,  in  gonorrhea,  215. 
malignant  tumors  of,  310. 
non-operative   treatment  for   strict- 
ure of,  305. 
palpation  of,  281. 

in  a  squatting  position,  305. 
plugs  for  stricture  of,  306. 
polyp  of,  30S. 

rapid  dilatation  of  stricture  of,  306. 
recurrence  of  prolapse  of,  319. 
sarcoma  of,  317. 
secondary  hemorrhage  of,  285. 
stools  in  stricture  of,  304. 
stricture  of,  304. 

gradual  dilatation  of,  306. 

intestinal  obstruction  in,  304. 

plugs  for,  306. 

rapid  dilatation  of,  306. 

stools  in,  304. 

treatment  for,  non-operative,  305. 
suture  of  wounds  of,  284. 
syphilis  of,  301. 
treatment,  for  abscess  of,  293. 

for  chronic  prolapse  of,  320. 

for  ulcer  of,  303. 

for  wounds  of,  284. 
tuberculous  fistula  of,  298. 
ulcer  of,  301. 

symptoms  of,  302. 
wounds  of,  284. 
Recurrence,  of  hydrocele,  240. 
of  ganglion,  447. 
of  phimosis,  251. 
of  prolapse  of  rectum,  319. 
of  ulcer  of  leg,  522,  526. 
Recurrent  bandage,  of  finger,  656. 

of  head,  601. 

of  stump,  680. 


Recurrent  sprain  of  ankle,  496. 
Reduction,  of  dislocation,  347. 

of  fractured  clavicle  by  operation, 
166. 

of  hemorrhoids,  31 1. 

of  prolapsed  hemorrhoid,  313. 

of  retracted  foreskin,  205. 
Reenforcing  gypsum  splint,  709. 
Reinfection  of  chancroids,  299. 
Relations,  of  great  trochanter  to  ilium, 
488. 

of  tendons  above  the  wrist,  343. 
Relaxation  of  sphincter  of  bladder,  272. 
Relief  of  retention  of  urine,  219. 
Removal,  of  bullet,  14. 

of  displaced  coccyx,  183. 

of  enlarged  glands  of  neck,  142. 

of  epithelioma  of  lower  lip,  101. 

of  floating  cartilage,  485. 

of  fluid  from  knee-joint,  500. 

of  foreign  body  from  hand,  337. 
from  urethra,  260. 
from  vagina,  260. 

of  gouty  deposit,  435. 

of  gypsum  splint,  706. 

of  hypertrophic  tonsil,  87. 

of  infected  inguinal  glands,  224. 

of  mole,  78. 

of  old  nail  in  paronychia,  410. 

of  pediculi,  130. 

of  powder  grains,  8. 

of  splinter,  14. 

of  suppurating  gland,  431. 

of  testicle,  235. 

of  thyroid  gland,  147. 

of  tongue  for  epithelioma,  103. 

of  tumor,  576. 

of  undescended  testicle,  254. 

of  varicose  veins,  539. 

of  whole  testicle  for  tuberculosis,  229. 
Repair  after  a  burn,  29. 
Reposition  of  fractured  bone,  368. 
Resection,  of  accessory  tendons,  470. 

of  chancre,  226. 

of  elbow-joint  after  fracture,  376. 

of  mucous  membrane  for  polyp  of 
cervix,  271. 

of  rib  for  tuberculosis,  178. 
Rest  in  gonorrhea,  214. 
Restoration  of  function  after  fracture, 
369. 


INDEX 


821 


Results,  after  circumcision,  2.50. 

after  operation  for  ingrown  nail,  548 
in  minor  surgery,  563. 
Retention  cysts  of  infancy,  182. 
Retention  of  urine,  219. 

catheterization  for,  219. 
causes  of,  219. 
in  female,  273. 
Retraction  of  foreskin  at  birth,  245. 
of  nipple  in  cancer  of  breast,  180. 
of  skin,  after  circumcision,  250. 
in  carcinoma  of  breast,  189. 
Retropharyngeal  abscess,  56. 
Reversing  a  bandage,  590. 
Rheumatism,  articular,  433. 

local  treatment  of,  433. 
Rheumatoid  arthritis,  434. 
Rhinitis,  chronic,  53. 

herpes  in,  53. 
Rhinophyma,  83. 

Rib,  adhesive  plaster  for  broken,  168. 
fracture  of,  167. 

treatment  for,  168. 
injury  of  periosteum  of,  167. 
tuberculosis  of,  178. 
Ribbon  bandage,  688. 
Rice  bodies  of  hand,  439. 
Rigidity  in  flatfoot,  557. 
Ringworm,  58. 

contagion  of,  58. 
Rodent  ulcer  of  face,  94. 
Roller  bandage,  588. 

general  principles  of,  588. 
materials  for,  589. 
Rolling  a  bandage,  589. 
Rosacea  hypertrophica  of  nose,  83. 
Rubber  drainage  tube,  695. 
Rubber  for  bandages,  688. 
"Run-around,"  407. 
Rupture,  of  bladder,  210. 

with  fracture  of  pelvis,  210. 
of  hemorrhoid,  310. 
of  hymen,  255. 

of  intraabdominal  organ,  155. 
of  ischiorectal  abscess,  293. 
of  lateral  ligament  of  knee,  491,  496. 
of  tendon,  475. 

of  tendon  of  plantaris  muscle,  475. 
of  urethra,  208. 
of  vagina,  255. 
of  vein  of  leg,  474. 


585. 


Sacroiliac  tuberculosis,  179. 
Saline  solution,  injection  of, 

use  of,  for  burns,  27. 
Salivary  cyst,  72. 
Salvarsan,  injection  of,  780. 

gangrene  due  to,  780. 
Sarcoma  and  epulis,  90. 
Sarccma,  compared  with  syphilis,  234. 
of  the  breast,  190. 
of  femur,  492. 
of  finger,  462. 
of  great  toe,  542. 
of  hand,  462. 
of  head,  104. 
of  knee,  542. 
of  lower  extremity,  542. 
of  rectum,  317. 
of  testicle,  234. 
of  trunk,  192. 
Sarcomatous  growth  of  mole,  77. 
Sayre  dressing  for  fracture  of  clavicle 

165. 
Scabies,  171. 
Scalp,  abscess  of,  38. 
abrasions  of,  7. 
contusions  of,  1. 
eczema  of,  57. 
epithelioma  of,  97. 
gumma  of,  63. 
hematoma  of,  3. 
preparation  of,  for  operation,  3. 
pulsating  angioma  of,  82. 
ringworm  of,  treatment  for,  58. 
sebaceous  cysts  of,  66. 
Scalp  wound,  drainage  of,  3. 
Scapula,  fracture  of,  167. 
Scar  from  alveolar  abscess,  47. 

mistaken  for  foreign  body,  336. 
Scissors  for  amputation  of  uvula,  112. 
Scrofulous  gums,  cure  of,  106. 
Scrotum,  abscess  of,  212. 
excision  of,  230. 
hematoma  of,  204. 
mucous  patches  on,  226. 
treatment  for  cancer  of,  234. 
Sebaceous  cyst,  diagnosis  of,  67. 
drainage  of,  70. 
inflammation  of,  67. 
of  head,  66. 
of  leg,  540. 
of  neck,  135. 


S22 


INDEX 


Sebaceous  cyst,  of  trunk,  181. 
operation  for,  69. 
treatment  for,  68. 
Sebaceous  material   beneath  foreskin, 

231. 
Secondary  hemorrhage  of  rectum,  285. 
Section,  of  finger  showing  site  of  an  al>- 
scess,  406. 
of  lumbar  spine,  581. 
of  great  toe,  showing  nail,  545. 
Separation  of  epiphysis,  370. 
Septum,  nasal,  submucous  excision  of, 
109. 
deviation  of,  109. 
tumor  of,  92. 
Sequestrum  of  lower  jaw,  43. 
Serous  cyst  of  prepuce,  231. 
Serous  synovitis,  344. 

of  lower  extremity,  483. 
Serum  in  a  joint  after  sprain,  339. 
Serum  therapy,  787. 
Sheath  of  tendon,  pus  in,  412. 
Shock  in  sprain  of  neck,  123. 
Short  frenum  of  penis,  251. 
Shortening  a  sign  of  fracture,  365. 
Shoulder,  ascending  spica  bandage  of, 
643. 
descending  spica  bandage  of,  644. 
dislocation  of,  350. 
neuritis  of,  342. 
sprain  of,  340. 
Shoulder-cap  for  fracture  of  humerus, 

372. 
Shoulder-joint,  effusion  into,  345. 

examination  of,  341. 
Significance  of  a  purulent  vaginal  dis- 
charge, 258. 
Signs  of  fracture,  363. 
Silk,  oiled,  689. 

sterilization  of,  693. 
use  of,  for  bandages,  688. 
for  skin  sutures,  572. 
for  sutures,  693. 
for  tendon  suture,  334. 
Silkworm  gut,  693. 
Silver  wire,  694. 
Simple  cyst  of  breast,  183. 
Simple  lipoma,  137. 
Simple  urethritis,  212. 
Simple  vulvitis,  261. 
Single  roller  bandage  of  head,  601. 


Sinking  of  transverse  arch,  500. 
Sitz  bath  for  fistula,  297. 
Sinus,  branchiogenic,  137. 

congenital,  near  ear,  76. 
frontal,  drainage  of,  54. 

pus  in.  53. 
in  tuberculosis  of  wrist,  442. 
of  urethra,  209. 

thyreoglossal,  recurrence  of,  136. 
Sinuses  and  cysts,  coccygeal,  181. 

umbilical,  181. 
Skin,  fibroma  of,  76. 

inflammations  of,  57. 
Skin-flaps,  elasticity  of,  576. 
Skingrafting,  577. 
after  burns,  29. 
for  cicatricial  deformity,  463. 
for  idcer  of  leg,  528. 
Skin-grafts,  dressing  for,  578. 

for  burns,  393. 
Skin-sutures,  silk  for,  572. 
Skull,  aberrant  thyroid  in,  105. 

fracture  of,  17. 
Slough  of  intestine  following  contusion, 

156. 
Sloughs  after  burns,  28. 
Solid  tumors  of  the  external  genitals. 

232. 
Solution,  Thiersch's,  15. 

in  operation,  565. 
Sound,  good  type  of,  218. 
Sores  of  back  from  lying  in  bed,  175. 
Spasm,  of  sphincter  ani,  290. 

of  sphincter  in  ulcer  of  rectum,  302. 
with  chancroid,  300. 
Specific  urethritis,  213. 
Speculum,  bivalve,  for  rectum,  283. 
inspection  of  rectum  through,  283. 
rectal,  282. 
urethral,  259. 
Sphincter  ani,  incontinence  of,  321. 
spasm  of,  290. 

with  chancroid,  300 
stretching  of,  282. 
Spica  bandage,  of  both  breasts,  632. 
of  foot,  677. 
of  great  toe,  678. 
of  one  breast,  630. 
of  thumb,  652. 
Spica  bandages,  593. 
Spina  bifida,  201. 


INDEX 


823 


Spinal  anesthesia,  583. 

dose  of  cocain  in,  583. 
Spinal  column,  sprain  of,  161. 
Spinal  cord,  injury  of,  in  fracture,  124. 
Spinal  puncture,  581. 
Spine,  cervical  fracture  of,  124. 
railroad,  injuries  of,  161. 
sprain  of,  122. 
tests  for  injury  of,  161. 
treatment  for  injury  of,  163. 
tuberculosis  of,  179. 
Spiral  bandage,  of  arm,  644. 

of  toe,  678. 
Spiral  reverse  bandage,  of  finger,  653. 
of  forearm,  647. 
of  hand,  651. 
of  leg,  670. 
of  thigh,  664. 
Spiral  reverse  of  bandage,  590. 
Spirocheta  pallida,  225. 
Splint,  angular,  699. 
circular  gypsum,  703. 
coaptation,  698. 
for  burns,  393. 
for  fracture  of  lower  jaw,  22. 
for  hallux  valgus,  553. 
for  sprain  of  knee,  492. 
from  wire  netting,  699. 
interdental,  22. 
metal,  698. 
nasal,  19. 
tin,  699. 
wood,  698. 
Splinter,  removal  of,  14. 

in  wound,  336. 
Sponges,  gauze,  683. 

gauze,  preparation  of,  684. 
Sprain,  338. 

active  motions  after,  339. 
of  ankle,  493. 

adhesive  strapping  for,  494. 
hot  fomentations  for,  495. 
ice-bag  for,  495. 
recurrent,  496. 
slight,  treatment  for,  493. 
with  fracture  of  malleolus,  495. 
of  back,  158. 
of  cervical  spine,  122. 
of  finger,  339. 
of  hip,  487. 

treatment  for,  489. 


Sprain,  of  knee,  489. 

differential  diagnosis  of,  491. 
splint  for,  492. 
1  reatment  for,  492. 
of  lower  extremity,  486. 
of  neck,  122. 
of  shoulder,  340. 
of  spinal  column,  161. 
of  thumb,  adhesive  plaster  strapping 

for,  340. 
passive  motion  after,  339. 
treatment  for,  339. 
Spur  of  nose,  92. 

Squatting  position  in  rectal  examina- 
tion, 281. 
Steno's  duct,  division  of,  16. 
Stenosis  of  the  cervix,  278,  279. 

dilatation  for,  279. 
Sterilization  of  catgut,  690. 

of  silk  sutures,  693. 
Sternoclavicular  articulation,  tubercu- 
losis of,  178. 
Sternomastoid  muscle,  abscess  under, 
131. 
fibroma  of,  140. 
Sternum,  fracture  of,  167. 
Stimson's  method  of  reducing  a  dislo- 
cated humerus,  351. 
Stitch,  mattress,  for  tendon,  333. 
Stockinette  bandages,  687. 
Stockinette  for  a  plaster  jacket,  687. 
Stomatitis,  55. 

Stools  in  stricture  of  rectum,  304. 
Stovain,  dose  of,  584. 
Straight  and  curved  skin  needles.  573. 
Strain  of  testicle,  206. 
Strangulated  hernia,  198. 
Strangulation  of  hemorrhoid,  311. 
Strapping,  a  joint  with  adhesive  plaster, 
493. 
a  sprained  back,  159. 
Strap-splints,  707. 

for  fracture  of  the  malleoli,  506. 
Stretching  foreskin,  245. 
Stretching  of  sphincter  ani,  282. 

for  fissure,  291. 
Stricture,  examination  of  urethra  for, 
217. 
gradual  dilatation  of,  218. 
of  anus,  304. 
of  rectum,  304. 


824 


INDEX 


Stricture,  of  re<  turn,  after  syphilitic  ul- 
ceration, 303. 
congenital,  323. 
from  ulcer.  303. 
operative  treatment  for,  305. 

of  urethra.  '_M7. 
Strip  gauze,  685. 
Stump,  recurrent  bandage  of,  080. 

dressing  of,  680. 
Sty.  37. 

Subconjunctival  ecchymosis,  2. 
Subcutaneous    dissection    of    varicose 

veins,  540. 
Subcutaneous  infusion,  585. 
Subcuticular  suture.  14,  573. 
Subdeltoid  bursitis,  340. 
Subgluteal  bursitis,  480. 
Subluxation  of  jaw,  24. 

of  radius,  354. 
Sublimis  tendons,  test  for  division  of, 

330. 
Sublingual  salivary  cyst,  71. 
Submaxillary  gland  mistaken  for  en- 
larged lymphatic  glands,  142. 
Submucous  excision  of  septum,  109. 
Subperiosteal  hematoma  of  leg,  473. 
Substitutes  for  cotton,  683. 
Sunburn,  29. 

of  lip,  29. 

prevention  of,  29. 
Superior  maxilla,  fracture  of,  19. 
Superior  maxillary  nerve  injected  with 

alcohol,  783. 
Supernumerary  finger,  468. 
Supernumerary  thumb,  468. 
Supernumerary  toe,  562. 
Support  for  sunken  nose,  108. 
Suprapubic   cystotomy   for   retention, 

220. 
Suppuration,  in  antrum  of  Highmore,  54. 

in  Bartholin's  gland,  incision  for,  264. 

in  cellulitis,  34. 

in  compound  fracture,  387. 

in  finger,  incision  for,  411. 

in  finger-joint,  tin  splint  for,  425. 

in  frontal  sinus,  53. 

in  hand,  412. 

in  hang-nail,  410. 

in  joint,  drainage  for,  425. 
in  hallux  valgus,  554. 

in  minute  wounds,  332. 


Suppuration,  in  neck,  130. 

in  palm,  1 1  I. 

in  tendon  sheath,  111. 

followed  by  contraction  of  finger, 

421. 
result  of,  421. 

umbilical,  175. 
Suppurative,  arthritis  of  hand,  423. 
with  loss  of  bone,  124. 

bursitis  of  toe,  551. 

olecranon  bursitis,  427. 

prepatellar  bursitis,  477. 

synovitis,  of  hand,  423. 
of  knee-joint,  532. 
of  lower  extremity,  532. 
treatment  for,  532. 

thecitis,  411. 

wound,  drainage  in,  572. 
Suprarenal  extract  to  control   hemor- 
rhage, 258. 
Surgical  dressings,  681. 
Surplus  skin  after  circumcision,  251. 
"  Sure  cure  "  of  ulcer  of  leg,  522. 
Suture,  for  phimosis,  249. 

of  hyoid,  123. 

of  incised  vein,  118. 

of  laceration  of  perineum,  256. 

of  nerves,  334. 

of  skin,  horsehair  for,  573. 

of  tendons,  332. 

of  urethra,  209. 

of  wounds  of  air  passage,  119. 

of  wounds  of  lip,  15. 

of  wounds  of  rectum,  284. 

replacing  of,  by  hooks,  574. 

subcuticular,  14. 
Sutures,  689. 

absorbable,  690. 

interrupted,  572. 

non-absorbable,  693. 

of  horsehair,  693. 

silk,  693. 

subcuticular,  573. 
Suturing  of  wounds,  572. 
Swelling,  after  fracture,  364. 

in  abscess  of  palm,  413. 

of  lymphatic   glands  from  decayed 
teeth,  41. 

of  tuberculous  joint  to  be  measured, 
441. 
Symptoms,  of  chronic  hemorrhoids,  31. 


INDEX 


825 


Symptoms,  of  contusion  of  abdomen, 
154. 

of  fistula,  296. 

of  internal  hemorrhage,  155. 

of  ischiorectal  abscess,  292. 

of  suppurative  thecitis,  412. 

of  ulcer  of  rectum,  302. 
Synovitis,  of  hand,  suppurative,  423. 

of  knee,  serous  chronic,  484. 

serous,  344. 

suppurative,  treatment  for,  425. 
Syphilis,  268. 

cervical  glands  enlarged  in,  145. 

internal  treatment  for,  61. 

local  treatment  for,  61. 

micro-organism  of,  225. 

of  anus,  300. 

of  cheek,  59. 

of  hand,  435. 

of  head,  59. 

of  lip,  59. 

of  lower  extremity,  534. 

of  male  genitals,  225. 

of  rectum,  301. 

of  testicle,  226. 

sarcoma  compared  with,  234. 

of  tongue,  59. 

of  trunk,  177. 

papilloma  mistaken  for,  76. 

tertiary  lesions  of,  63. 
Syphilis  and  epithelioma,  98. 
Syphilitic,  condylomata  about  anus, 300. 

dactylitis,  436. 

eczema  of  finger,  432. 

glossitis,  63. 

orchitis,  226. 

periostitis  of  tibia,  534. 

Tear-duct,  obstruction  of,  108. 
Technique  of  vaccination,  587. 
Ten-day  catgut,  692. 
Tendo  Achillis,  bursa  under,  481. 
Tendon,  animal,  692. 

elongation  of,  333. 

kangaroo,  692. 

method  of  lengthening  of,  464. 

rupture  of,  475. 

suture  of,  332. 
Tendon  sheath,  pus  outside  of,  418. 

suppuration  in,  411. 
result  of,  421. 


Tendon  sheath,  tuberculosis  of,  439. 
Tendon  suture  by  long  silk  thread,  334. 
Tendons,  above  wrist,  relations  of,  '.'A'.'>. 
division  of,  476. 

in  wrist,  division  of,  329. 

of  hand,  too  many  accessory,  469. 
Tenosynovitis,  acute  non-suppurative, 
343. 

dry,  344. 
Tension,  tying  knot  under,  573. 
Terminal  extremity  of  bandage,  589. 
Tertiary  lesions  of  syphilis,  63. 
Testicle,  cancer  and  syphilis  of,  com- 
pared, 228. 

carcinoma  of,  234. 

contusion  of,  204. 

cysts  of,  232. 

descent  of,  253. 

gumma  of,  227. 

injury  of,  203. 

neuralgia  of,  206. 

position  of,  in  hydrocele,  238. 

removal  of,  235. 

sarcoma  of,  234. 

strain  of,  206. 

syphilis  of,  226. 

tuberculosis  of,  229. 

compared  with  syphilis,  228. 

undescended,  253. 
removal  of,  254. 
treatment  for,  253. 

within  abdomen,  254. 
Tests,  for  injury  of  spine,  161. 

for   division   of   profundus   tendons, 
330. 

for  division  of  sublimis  tendons,  330. 

for  false  point  of  motion,  366. 

for  flatfoot,  557. 

of  functions  of  a  joint,  488. 
Thecitis,  suppurative,  411. 

symptoms  of,  412. 
Thick  lips,  115. 
Thiersch  grafts,  578. 
Thiersch's  solution,  15. 
Thigh,  spiral  reverse  bandage  of,  664. 
Thread,  celluloid,  694. 

cotton  and  linen,  694. 
Throat,  foreign  bodies  in,  12. 

inflammations  of,  55. 
Thrombosis  of  leg,  515. 
Thumb,  abscess  of  tip  of,  406. 


826 


INDEX 


Thumb,  adhesive  plaster  strapping  for 
sprain  of,  340. 

dislocation  of,  349,  355. 
operation  for,  357. 
radiograph  in,  349. 

dislocation  of  phalanx  of,  355. 

incision  for  abscess  of,  417. 

overextension  of,  357. 

spica  bandage  of,  ii"v-'. 

supernumerary,  168. 
Thyreoglossal  cyst,  135. 

sinus,  recurrence  of,  136. 
Thyroid,   mortality   after  fracture  of, 
124. 

tumors  of.  145. 
Thyroid  gland,  removal  of,  147. 
Tibia  and  fibula,  fracture  of,  504. 
Tibia,  non-union  of,  501. 

osteoma  of,  541. 

syphilitic  periostitis  of,  534. 
Tibial  fracture  with  delayed  union,  501. 
Tin  splint  for  suppuration  in  a  joint  of 
finger,  425. 

splints,  699. 
Toe,  amputation  of,  510. 

circular  bandage  of,  678. 

complex  spica  bandage  of,  679. 

gangrene  of,  513. 

hypertrophy  of,  561. 

osteoma  of,  541. 

perforating  ulcers  of,  531. 

sarcoma  of,  542. 

section  of,  showing  nail,  545. 

spica  bandage  of,  678. 

spiral  bandage  of,  678. 

supernumerary,  562. 

suppurative  bursitis  of,  551. 
Toe-nail,  hematoma  under,  472. 
Tongue,  abscess  of,  38. 

epithelioma  of,  98,  103. 
early  diagnosis  of,  103. 

leucoplakia  of,  98. 

syphilis  of,  59. 
Tongue-tie,  115. 
Tonsil,  blunt  dissection  of,  89. 

cancer  of,  107. 

hypertrophic,  removal  of,  87. 

hypertrophy  of,  86. 

compared  with  malignant  growths 

of,  107. 
of  lingual,  87. 


Tonsil,  instruments  for  removal  of,  SS. 

malignant  growth  of,  107. 

treatment  following  removal  of,  89. 
Tonsillectomy,  87. 

instruments  for,  S8. 

local  anesthetic  for,  89. 
Tonsillitis,  abscess  in,  55. 
Tooth,  eruption  of  wisdom,  24. 

extraction  of  decayed.   15. 
Toothache  a  sign  of  infection,  4.">. 
Torticollis,  14S. 

position  of  head  in,  149. 

treatment  of  acute,  150. 
Toughening  of  nipples  by  massage,  174. 
Trachea,  fracture  of,  124. 
Tracheotomy,  110. 

for  foreign  body,  118. 

instruments  for,  120. 
Trachoma,  50. 

wel  applications  for,  50. 
Transfusion,  584. 

of  blood,  777. 
Transverse  arch,  sinking  of,  560. 
Transverse  flatfoot,  560. 
Transverse  section  of  lumbar  spine,  582. 
Traumatic  ulcers  of  hand,  331. 
Traumatism,  blisters  from,  325. 
Treatment,  after  tonsillectomy,  89. 

for  abscess,  38. 
of  rectum,  293. 

for  acne,  33. 

for  acute  hemorrhoid,  310. 

for  acute  prolapse  in  infants,  318. 

for  acute  torticollis,  150. 

for  adenofibroma  of  breast,  188. 

for  adenoids,  89. 

for  alveolar  abscess,  45. 

for  angioma  by  operation,  82. 

for  bed-sore,  175. 

for  black  eye,  2. 

for  blister,  325,  471. 

for  boils,  36,  126. 

for  bubo,  224. 

for  burns  by  exposure,  27. 

for  burns  of  second  degree,  26. 
of  third  degree,  28. 

for  bursitis  of  foot,  483. 

for  callus,  537. 

for  cancer  of  penis,  234. 
of  scrotum,  234. 

for  capillary  angioma,  80. 


INDKX 


827 


Treatment,  for  carbuncle  of  neck,  128. 
for  cellulitis,  34. 
for  chancre,  225. 
for  chancroid,  224. 
for  chronic  lymphadenitis,  142. 
for  chronic  prolapse  of  the  rectum, 

320. 
for  cleft  palate,  114. 
for  conjunctivitis,  48. 
for  contusion  of  abdomen,  156. 
for  corn,  538. 
for  dermoid  cyst,  75. 
for  dislocation,  347. 

of  finger,  359. 
for  erysipelas,  35. 
for  fracture,  368. 

of  patella,  499. 

of  rib,  168. 

of  spine,  169. 
for  fractured  clavicle,  164. 
for  fissure,  290. 
for  fistula,  297. 
for  flatfoot,  558. 
for  frost-bite,  394. 
for  ganglion,  446. 

by  punctures,  448. 
for  gangrene  of  finger,  397. 
for  gonorrhea,  213. 

in  female,  262. 

of  rectum,  299. 
for  hallux  valgus,  551. 
for  incontinence  of  childhood,  221. 
for  ingrown  nail,  546. 
for  injury  of  spine,  163. 
for  ischiorectal  abscess,  293. 
for  keloid,  184. 
for  lipoma,  137. 
for  phlebitis,  516. 
for  pinworms,  287. 
for  posterior  urethritis,  216. 
for  prepatellar  bursitis,  479. 
for  proctitis,  289. 
for  pruritus,  287. 
for  ragged  wounds,  14. 
for  rectal  hemorrhage,  285. 
for  retracted  nipples,  174. 
for  rheumatism  locally,  433. 
for  rupture  of  the  urethra,  209. 
for  sebaceous  cyst,  68. 
for  slight  sprain  of  the  ankle,  493. 
for  sprain,  339. 


Treatment  for  sprain,  of  back,  158. 
of  hip,  489. 
of  knee,  492. 
of  shoulder,  342. 

for  suppurative  synovitis,  425,  532. 

for  trachoma,  50. 

for  tuberculous  arthritis,  443. 

for  ulcer  of  leg,  general  measures  in, 
526. 

for  ulcer  of  rectum,  303. 

for  undescended  testicle,  253. 

for  varicocele,  243. 

for  varicose  veins,  539. 

for  vulvitis,  262. 

for  warts,  459. 

for  wounds,  13. 

for  wounds  of  rectum,  284. 

internal,  for  syphilis,  61. 

local,  for  syphilis,  61. 
Trichiasis,  50. 
Trocar  and  cannula,  method  of  holding, 

200. 
Trochanter,  fracture  of,  497. 
Trunk,  bandages  of,  626. 

burns  of,  170. 

carcinoma  of,  191. 

cellulitis  of,  172. 

cystic  tumors  of,  181. 

dermoid  cysts  of,  182. 

fibroma  of,  185. 

injuries  of,  153. 

keloid  of,  184. 

lipoma  of,  185. 

papilloma  of,  185. 

sarcoma  of,  192. 

sebaceous  cysts  of,  181. 

syphilis  of,  177. 

tuberculosis  of,  178. 

wounds  of,  156. 
Truss,  198. 

Tube,  after  tracheotomy,  insertion  of, 
119. 
care  of,  120. 

withdrawal  of  an  intubation,  122. 
Tubercle,  anatomical,  399. 
Tuberculosis,  castration  for,  230. 

cervical,  133. 

costal,  178. 

muscular  spasm  in,  489. 

of  anus,  301. 

of  arm,  440. 


828 


INDEX 


Tuberculosis,  of  breast,  180. 
of  (-loi-s.il  vertebra',  179. 
of  face,  63. 
of  hip,  535. 

of  lower  extremity,  535. 
■  <•;'  mammary  gland,  180. 
of  mouth,  64. 
of  neck,  133. 

plaster  of  Paris  bandage  for,  134. 
of  rectum,  301. 
of  rib,  178. 

of  seminal  vesicles,  229. 
of  spine,  133,  179. 
of  sternoclavicular  articulation,  17s. 
of  tendon  sheaths,  439. 
of  testicle,  229. 
of  trunk,  178. 
of  upper  extremity,  442. 
of  wrist  with  sinus,  442. 
removal  of  whole  testicle  for,  229. 
resection  of  rib  for,  178. 
sacroiliac,  179. 
Tuberculosis   and    syphilis    of   testicle 

compared,  228. 
Tuberculous  cystitis,  229. 
glands  of  neck,  142. 

suppurating,  144. 
fistula  of  rectum,  298. 
ischiorectal  abscess,  295. 
joint,  loss  of  function  in,  442. 

measurements  of,  441. 

pain  in,  442. 
nodules,  in  epididymis,  229. 

in  the  vas  deferens,  229. 
Tumors,  of  anus,  307. 
of  arm,  445. 
of  bladder,  235. 
of  foot,  537. 
of  hand,  445. 
of  head, 66. 

benign,  76. 

cystic,  66. 

malignant,  92. 
of  leg,  537. 
of  male  breast,  191. 
of  male  genitals,  232. 
of  nasal  septum,  92. 
of  neck,  135. 
of  parotid,  106. 
of  prostate,  235. 
of  thyroid  gland,  145. 


Tumors,  of  tonsil,  malignant,  107. 

removal  of,  576. 

solid,  of  breast,  1ST. 
Tunica  vaginalis,  fluid  in,  236. 
Turbinate  bone,  hypertrophy  of,  53. 
Twisted  nails,  oil. 
Tying  ligatures,  method  of,  568. 
Types  of  local  inflammation,  399. 

Ulcer,  from  vaccination,  432. 
of  face,  59. 
of  leg,  519. 

acute,  inflammation  in,  523. 
carcinomatous,  543. 
cause  of,  521. 
eczema  in,  524. 

elastic  rubber  stocking  after,  5:27. 
exposing  bone,  529. 
flannel  bandage  for,  527. 
general  treatment  for,  526. 
growth  of  epithelium  in,  524. 
measures  for  cleansing,  523. 
measures  for  stimulation  of,  523. 
operative  treatment  for,  528. 
predisposing  causes  of,  520. 
recurrence  of,  522,  526. 
skin-grafting  for,  528. 
"  sure  cure  "  for,  522. 
varicose  veins  in,  538. 
venous  engorgement  in,  525. 
of  rectum,  301. 

spasm  of  sphincter  in,  302. 
rodent,  of  face,  94. 
stricture  of  rectum  from,  303. 
Ulceration  of  epithelioma,  95. 

of  rectum  after  syphilitic  stricture, 
303. 
Ulna,  fracture  of,  376. 
Ulna  and  radius,  backward  dislocation 
of,  353. 
involved  in  Colles's  fracture,  380. 
or  radius,  fracture  of,  378. 
Ulnar  artery,  position  of,  328. 

nerve,  division  of,  329. 
Umbilical  cysts  and  sinuses,  181. 
hernia,  196. 
suppuration,  175. 
Umbilicus,  granuloma  of,  183. 

hemorrhage  from,  156. 
Unbleached  cotton,  681. 
muslin,  686. 


INDEX 


820 


Undescended  testicle,  253. 

and  hernia,  254. 
Unimpacted  fracture  of  neck  of  femur, 

489. 
Unreduced  dislocation,  350. 
Unusual  types  of  hydrocele,  240. 
Upper  extremity,  bandages  of,  643. 
compound  fractures  of,  386. 
dislocations  of,  347. 
fractures  of,  363. 
injuries  of,  324. 
tuberculosis  of,  442. 
Urethra,  275. 
calculus  of,  207. 
cauterization  of  prolapsed,  274. 
diagnosis  of  rupture  of,  209. 
divulsion  of,  217. 
extraction  of  foreign  body  from,  207. 

of  pin  from,  207. 
female,  275. 
fistula  of,  252. 
foreign  bodies  in,  207,  258. 
good  type  of  steel  sound  for,  218. 
inflammation  of,  213. 
operation  for  prolapse  of,  275. 
passage  of  steel  sound  into,  218. 
prolapse  of,  275. 

removal  of  foreign  bodies  from,  260. 
rupture  of,  208. 

treatment  for,  209. 
sinus  of,  209. 
stricture  of,  217. 

treatment  for,  217. 
sudden  dilatation  of,  217. 
suture-of,  209. 

urethroscope  for  examination  of  fe- 
male, 259. 
Urethral  caruncle,  270. 

speculum,  259. 
Urethritis,  absence  of  gonococci,  212. 
chronic,  216. 
gonorrheal,  263. 
posterior,  216. 

treatment  for,  216. 
simple,  212. 
specific,  213. 
Urethroscope  for  examination  of  female 

urethra,  259. 
Urethrotomy,   external,   retention  for, 
220. 
internal,  218. 


Urine,  blood  in,  210. 
catheterization  for  retention  of,  219 

extravasation  of,  210. 
incontinence  of,  220,  272. 
retention  of,  219. 
causes  of,  219. 
in  female,  273. 
relief  from,  219. 
Urticaria,  31. 

distinguished  from  eczema,  432. 
local  treatment  for,  31. 
Use  of  probe  in  rectal  disease,  280. 
Uterus,  curettage  of,  267. 

introduction  of  gauze  within,  258. 
operations  for  prolapse  of,  277. 
prolapse  of,  275. 
pessary  for,  276. 
Uvula,  amputation  of,  111. 

astringent  for  relaxation  of,  111. 
elongation  of,  1 10. 
Uvula  scissors,  112. 

Vaccination,  587. 

ulcer  from,  432. 
Vaccine  therapy,  787. 
Vagabond's  disease,  518. 
Vagina,  fistula  of,  277. 

foreign  bodies  in,  258. 

hematoma  of,  255. 

removal  of  foreign  bodies  from,  260. 

rupture  of,  255. 
Vaginal  and  rectal  examination,  305. 
Vaginal  catarrh,  265. 
Vaginal  discharge,  pruritus  due  to,  261. 

significance  of  a  purulent,  258. 
Vaginitis,  261. 
Varicocele,  241. 

impulse  on  coughing  in,  243. 

ligation  of  dilated  veins  in,  244. 

partial  excision  of  scrotum  in,  244. 

treatment  of,  243. 
Varicose  ulcer,  521. 
Varicose  veins,  ligation  of,  539. 
relation  to  ulcer  of  leg,  538. 
removal  of,  539. 

subcutaneous  dissection  of,  540. 
treatment  for,  539. 
Varix  of  hand,  449. 
Vas  deferens,  evulsion  of,  230. 

tubercular  nodule  in,  229. 
Vein,  ligation  of,  474. 


S30 


1XDKX 


Vein  of  leg,  rupture  of,  474. 

suture  of  incised,  118. 

wounds  of  jugular,  118. 
Velpeau'a  bandage,  635. 
Venereal  warts.  232. 

about  the  anus,  307. 
Venesection,  585. 
Venous  engorgement,  525. 
Vertebra,  fracture  of,  169. 
Vertebra,  dislocation  of,  125,  170. 

tuberculosis  of,  133,  179. 
Vesical  calculus,  221. 
Vesicles,  tuberculosis  of  seminal,  229. 
Vessels,  ligation  of,  332. 
Vulva,  carcinoma  of,  271. 

chancroid  of,  268. 

condyloma  of,  269. 

eczema  of,  261. 

gonorrhea  of,  262. 

itching  of,  260. 

papilloma  of,  270. 
Vulvitis,  gonorrheal,  262. 

simple,  261. 

treatment  for,  262. 

Wart,  458. 

epithelioma  mistaken  for,  95. 

malignant  growth  in,  92. 

of  anus,  removal  of,  308. 

of  hand,  458. 

of  penis,  233. 

treatment  for,  459. 

venereal,  232. 
Web-finger,  467. 

incision  and  suture  for,  467. 
Wet  applications  in  trachoma,  50. 
Wet-cupping,  586. 
Wet  dressings,  575. 
for  abrasions,  7. 
for  wounds,  575. 
for  wounds  of  hand,  30. 
heat  of,  127. 
Wetting  the  bed,  220. 
Wheel  injury,  154. 
Whitlow,  411. 

Wire  cloth  in  gypsum  bandages,  709. 
Wire  netting,  699. 
Wisdom  tooth,  eruption  of,  24. 
Withdrawal  of  an  intubation  tube,  122. 
Wolfe  grafts,  579. 
Wood  splints,  698. 


Wood  wool,  683. 

Wounds,  dressings  for,  574.  682. 

effect  of  dry  dressing,  419. 

glass  in,  336. 

infection  of,  399. 

methods  of  draining,  570. 

of  anus,  284. 

of  arm,  330. 

of  cheek,  suture  of,  15. 

of  esophagus,  119. 

of  external  genitals,  208 

of  eye,  14. 

of  hand,  330. 

foreign  bodies  in,  336. 

of  head,  13. 

of  joint,  infection  in,  475. 

of  joints,  335. 

of  jugular  vein,  118. 

of  knee-joint,  475. 

of  lip,  suture  of,  15. 

of  lower  extremity,  475. 

of  mouth,  15. 

of  neck,  118. 

of  periosteum,  16. 

of  rectum,  284. 

of  scalp,  drainage  of,  3. 

of  trunk,  156. 

splinter  in,  336. 

suppuration  in  minute,  332. 

suturing  of,  572. 

treatment  of,  13. 

wet  dressings  for,  575. 
Wrist,  division  of  tendons  in,  329. 

dislocation  of,  355. 

fibrolipoma  of,  454. 

ganglion  of,  445. 
operation  for,  446. 

relations  of  tendons  above,  343. 
Wryneck,  148. 

diagnosis  of,  149. 
from  myositis,  148. 

manipulation  for,  151. 

operation  for,  151. 

position  of  head  in,  149. 

X-ray  and  cancer,  104. 
burn,  30. 

for  epithelioma,  104. 
examination  in  fracture,  365. 
foreign  body  located  by,  118. 

Zoster,  172. 


(8) 


COLUMBIA   UNIVERSITY 

This  bogjc  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 


DATE  BORROWED 

DATE  DUE 

DATE   BORROWED 

DATE  DUE 

C28<638)M50 

\    RD111  F73 

1914 
Foote 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.stx) 

RD  111  F73  1914  C.1 

A  text-booik,ofiimiinor|isii  iraen |iiminii|ll«||H 
"2002102102 


